| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,546 |
992 |
$605K |
| D1120 |
Prophylaxis - child |
13,009 |
12,949 |
$446K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,774 |
1,496 |
$371K |
| D0120 |
Periodic oral evaluation - established patient |
12,541 |
12,483 |
$304K |
| D1206 |
Topical application of fluoride varnish |
15,370 |
15,296 |
$296K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,527 |
1,167 |
$261K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,366 |
1,267 |
$246K |
| D1110 |
Prophylaxis - adult |
2,792 |
2,781 |
$130K |
| D0272 |
Bitewings - two radiographic images |
5,479 |
5,444 |
$115K |
| D1351 |
Sealant - per tooth |
2,718 |
921 |
$103K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,223 |
3,051 |
$102K |
| D0240 |
|
2,582 |
2,571 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,177 |
2,177 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,587 |
2,573 |
$70K |
| D0350 |
|
853 |
834 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
3,931 |
3,878 |
$49K |
| D0330 |
Panoramic radiographic image |
814 |
814 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
946 |
925 |
$34K |
| D0274 |
Bitewings - four radiographic images |
895 |
894 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
1,558 |
1,543 |
$21K |
| D1354 |
|
798 |
229 |
$13K |
| D7240 |
Removal of impacted tooth - completely bony |
42 |
13 |
$11K |
| D9219 |
|
263 |
263 |
$11K |
| D2934 |
|
44 |
12 |
$7K |
| D3120 |
|
119 |
66 |
$5K |
| D1352 |
|
86 |
43 |
$3K |
| D1353 |
|
49 |
28 |
$2K |