| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,578 |
1,177 |
$576K |
| D1120 |
Prophylaxis - child |
11,152 |
11,063 |
$396K |
| D0120 |
Periodic oral evaluation - established patient |
11,313 |
11,241 |
$281K |
| D1206 |
Topical application of fluoride varnish |
12,538 |
12,432 |
$256K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,351 |
815 |
$135K |
| D1110 |
Prophylaxis - adult |
2,677 |
2,659 |
$133K |
| D0272 |
Bitewings - two radiographic images |
4,672 |
4,630 |
$99K |
| D1351 |
Sealant - per tooth |
2,704 |
785 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,276 |
2,260 |
$93K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,718 |
2,534 |
$85K |
| D0330 |
Panoramic radiographic image |
1,197 |
1,187 |
$63K |
| D0240 |
|
511 |
501 |
$17K |
| D0274 |
Bitewings - four radiographic images |
514 |
512 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
444 |
441 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
66 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
311 |
307 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
81 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
641 |
628 |
$8K |
| D9310 |
|
194 |
188 |
$8K |
| D1354 |
|
945 |
176 |
$6K |
| D9420 |
|
37 |
37 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$429.92 |