| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,785 |
719 |
$344K |
| D1120 |
Prophylaxis - child |
9,686 |
9,521 |
$323K |
| D0120 |
Periodic oral evaluation - established patient |
8,444 |
8,321 |
$202K |
| D1351 |
Sealant - per tooth |
6,828 |
1,517 |
$177K |
| D0272 |
Bitewings - two radiographic images |
7,176 |
7,066 |
$163K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,321 |
860 |
$110K |
| D1206 |
Topical application of fluoride varnish |
4,975 |
4,879 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,812 |
4,741 |
$93K |
| D7140 |
Extraction, erupted tooth or exposed root |
965 |
510 |
$90K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,118 |
739 |
$87K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,137 |
1,977 |
$66K |
| D0330 |
Panoramic radiographic image |
937 |
921 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,373 |
1,342 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,194 |
2,114 |
$29K |
| D9420 |
|
251 |
246 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,315 |
1,094 |
$14K |
| D0274 |
Bitewings - four radiographic images |
210 |
208 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
209 |
205 |
$6K |
| D1110 |
Prophylaxis - adult |
111 |
110 |
$5K |
| D1354 |
|
109 |
42 |
$2K |