| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,692 |
862 |
$496K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,359 |
992 |
$257K |
| D1120 |
Prophylaxis - child |
8,085 |
7,791 |
$179K |
| D1206 |
Topical application of fluoride varnish |
7,561 |
7,277 |
$127K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,144 |
3,990 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
4,382 |
4,211 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
282 |
$40K |
| D0330 |
Panoramic radiographic image |
842 |
817 |
$38K |
| D0272 |
Bitewings - two radiographic images |
3,358 |
3,273 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
420 |
394 |
$30K |
| D0240 |
|
2,066 |
1,115 |
$26K |
| D1351 |
Sealant - per tooth |
1,136 |
352 |
$25K |
| D1354 |
|
691 |
217 |
$11K |
| D0251 |
|
625 |
622 |
$8K |
| D0250 |
|
497 |
470 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
456 |
452 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
89 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,023 |
316 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
853 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
41 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
78 |
$3K |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$260.00 |
| D1320 |
|
12 |
12 |
$180.00 |
| D1310 |
|
296 |
288 |
$0.00 |
| D1330 |
|
293 |
285 |
$0.00 |
| D0602 |
|
60 |
60 |
$0.00 |
| D0603 |
|
223 |
214 |
$0.00 |