| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,493 |
1,547 |
$768K |
| D1351 |
Sealant - per tooth |
13,445 |
2,517 |
$370K |
| D1354 |
|
4,931 |
1,618 |
$358K |
| D1120 |
Prophylaxis - child |
10,751 |
9,677 |
$345K |
| D1206 |
Topical application of fluoride varnish |
13,632 |
12,365 |
$289K |
| D0120 |
Periodic oral evaluation - established patient |
10,368 |
9,458 |
$232K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,242 |
953 |
$166K |
| D0272 |
Bitewings - two radiographic images |
6,304 |
5,616 |
$140K |
| D1110 |
Prophylaxis - adult |
2,900 |
2,652 |
$139K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,497 |
3,095 |
$119K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,059 |
3,349 |
$118K |
| D0330 |
Panoramic radiographic image |
1,522 |
1,389 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
956 |
595 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,162 |
773 |
$67K |
| D0140 |
Limited oral evaluation - problem focused |
1,839 |
1,582 |
$57K |
| D0240 |
|
3,484 |
1,435 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,013 |
952 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
3,112 |
2,679 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,995 |
1,075 |
$21K |
| D1510 |
|
112 |
75 |
$18K |
| D2394 |
|
109 |
53 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
335 |
313 |
$11K |
| D2332 |
|
110 |
59 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
27 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
182 |
140 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
341 |
293 |
$2K |
| D2940 |
|
24 |
15 |
$1K |
| D1999 |
|
212 |
172 |
$553.00 |
| D3120 |
|
2,739 |
1,030 |
$0.00 |