| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,721 |
892 |
$867K |
| D1120 |
Prophylaxis - child |
7,358 |
7,082 |
$435K |
| D0120 |
Periodic oral evaluation - established patient |
5,179 |
4,988 |
$230K |
| D1351 |
Sealant - per tooth |
4,998 |
1,325 |
$219K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,555 |
494 |
$205K |
| D1206 |
Topical application of fluoride varnish |
7,176 |
6,912 |
$190K |
| D0274 |
Bitewings - four radiographic images |
3,028 |
2,923 |
$169K |
| D0140 |
Limited oral evaluation - problem focused |
1,898 |
1,764 |
$114K |
| D0272 |
Bitewings - two radiographic images |
2,198 |
2,120 |
$83K |
| D0240 |
|
2,155 |
1,085 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
957 |
926 |
$60K |
| D0330 |
Panoramic radiographic image |
588 |
568 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
790 |
737 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
1,555 |
1,484 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,779 |
512 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
160 |
$32K |
| D9420 |
|
306 |
298 |
$29K |
| D4355 |
|
132 |
129 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
247 |
241 |
$13K |
| D1110 |
Prophylaxis - adult |
99 |
94 |
$7K |
| D9310 |
|
70 |
66 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$3K |
| D1330 |
|
566 |
550 |
$0.00 |
| D3120 |
|
60 |
31 |
$0.00 |
| D0190 |
|
1,341 |
1,285 |
$0.00 |
| D1999 |
|
1,338 |
1,282 |
$0.00 |
| D1354 |
|
151 |
54 |
$0.00 |