| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,659 |
2,557 |
$694K |
| D1120 |
Prophylaxis - child |
20,779 |
19,558 |
$628K |
| D1206 |
Topical application of fluoride varnish |
22,859 |
21,520 |
$436K |
| D0120 |
Periodic oral evaluation - established patient |
20,650 |
19,488 |
$412K |
| D1351 |
Sealant - per tooth |
12,909 |
2,146 |
$313K |
| D0272 |
Bitewings - two radiographic images |
9,886 |
9,252 |
$207K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,922 |
1,541 |
$205K |
| D0330 |
Panoramic radiographic image |
2,403 |
2,264 |
$132K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,920 |
4,512 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,934 |
1,182 |
$122K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,740 |
1,578 |
$121K |
| D1110 |
Prophylaxis - adult |
2,477 |
2,340 |
$96K |
| D0140 |
Limited oral evaluation - problem focused |
2,449 |
2,292 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,520 |
2,333 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
3,828 |
3,511 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,130 |
1,433 |
$24K |
| D0274 |
Bitewings - four radiographic images |
660 |
615 |
$17K |
| D1354 |
|
94 |
37 |
$9K |
| D1510 |
|
14 |
12 |
$2K |