| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
6,398 |
1,337 |
$553K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,963 |
953 |
$356K |
| D1351 |
Sealant - per tooth |
14,661 |
3,236 |
$302K |
| D1120 |
Prophylaxis - child |
10,318 |
8,761 |
$245K |
| D1206 |
Topical application of fluoride varnish |
14,611 |
12,359 |
$229K |
| D0120 |
Periodic oral evaluation - established patient |
13,091 |
11,135 |
$225K |
| D1110 |
Prophylaxis - adult |
5,892 |
4,960 |
$216K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,155 |
1,638 |
$152K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,374 |
1,766 |
$127K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,977 |
897 |
$110K |
| D0140 |
Limited oral evaluation - problem focused |
3,948 |
3,267 |
$106K |
| D0272 |
Bitewings - two radiographic images |
5,561 |
4,721 |
$101K |
| D0330 |
Panoramic radiographic image |
2,688 |
2,176 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,239 |
2,697 |
$83K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
677 |
196 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,679 |
2,208 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,148 |
2,561 |
$64K |
| D0240 |
|
4,318 |
1,961 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
2,052 |
1,489 |
$50K |
| D9243 |
|
700 |
185 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,624 |
1,949 |
$17K |
| D9239 |
|
213 |
172 |
$12K |
| D1510 |
|
82 |
54 |
$11K |
| D2330 |
|
149 |
76 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
55 |
$7K |
| D7111 |
|
47 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
190 |
$2K |
| D1999 |
|
2,431 |
2,033 |
$1K |
| D9248 |
|
63 |
58 |
$577.50 |
| D2390 |
|
37 |
15 |
$140.00 |
| D1353 |
|
30 |
13 |
$0.00 |