| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,188 |
595 |
$308K |
| D1120 |
Prophylaxis - child |
6,364 |
5,927 |
$196K |
| D1354 |
|
2,596 |
910 |
$193K |
| D1206 |
Topical application of fluoride varnish |
7,524 |
7,018 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
6,377 |
5,987 |
$137K |
| D1351 |
Sealant - per tooth |
4,776 |
973 |
$126K |
| D0272 |
Bitewings - two radiographic images |
3,518 |
3,273 |
$78K |
| D7140 |
Extraction, erupted tooth or exposed root |
775 |
340 |
$61K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,419 |
1,265 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,297 |
1,177 |
$41K |
| D1110 |
Prophylaxis - adult |
927 |
864 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
822 |
761 |
$25K |
| D0240 |
|
1,272 |
571 |
$19K |
| D0330 |
Panoramic radiographic image |
270 |
261 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,379 |
1,188 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
41 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
365 |
328 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
106 |
95 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
66 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
89 |
$1K |
| D1999 |
|
196 |
170 |
$972.04 |
| D3120 |
|
910 |
287 |
$0.00 |