| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,293 |
358 |
$188K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,229 |
631 |
$158K |
| D1120 |
Prophylaxis - child |
3,475 |
3,475 |
$152K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,130 |
596 |
$114K |
| D1206 |
Topical application of fluoride varnish |
4,114 |
4,114 |
$104K |
| D7140 |
Extraction, erupted tooth or exposed root |
952 |
471 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,669 |
2,669 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,459 |
1,459 |
$62K |
| D1110 |
Prophylaxis - adult |
785 |
785 |
$46K |
| D1351 |
Sealant - per tooth |
1,048 |
397 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,854 |
1,854 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
850 |
841 |
$28K |
| D0330 |
Panoramic radiographic image |
473 |
473 |
$26K |
| D0350 |
|
293 |
272 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,898 |
1,884 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,240 |
1,237 |
$22K |
| D0274 |
Bitewings - four radiographic images |
511 |
511 |
$16K |
| D3120 |
|
326 |
191 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
201 |
$8K |
| D9420 |
|
62 |
62 |
$7K |
| D2934 |
|
38 |
12 |
$7K |