| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,462 |
1,521 |
$849K |
| D1120 |
Prophylaxis - child |
17,244 |
16,973 |
$752K |
| D1206 |
Topical application of fluoride varnish |
21,606 |
21,269 |
$535K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,289 |
2,886 |
$524K |
| D0120 |
Periodic oral evaluation - established patient |
15,553 |
15,321 |
$460K |
| D1351 |
Sealant - per tooth |
13,008 |
2,483 |
$440K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,787 |
1,250 |
$293K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,060 |
3,008 |
$160K |
| D0140 |
Limited oral evaluation - problem focused |
3,289 |
3,173 |
$144K |
| D1110 |
Prophylaxis - adult |
2,223 |
2,191 |
$134K |
| D0272 |
Bitewings - two radiographic images |
7,782 |
7,662 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,198 |
857 |
$113K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,695 |
5,251 |
$105K |
| D3120 |
|
2,825 |
861 |
$98K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,086 |
2,052 |
$85K |
| D0330 |
Panoramic radiographic image |
1,676 |
1,647 |
$72K |
| D1330 |
|
7,528 |
7,382 |
$47K |
| D2940 |
|
491 |
200 |
$24K |
| D0274 |
Bitewings - four radiographic images |
932 |
911 |
$21K |
| D0240 |
|
1,654 |
1,630 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,060 |
1,044 |
$10K |
| D2330 |
|
82 |
29 |
$7K |
| D9420 |
|
261 |
253 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
107 |
$2K |