| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,993 |
2,638 |
$853K |
| D1120 |
Prophylaxis - child |
16,553 |
16,304 |
$768K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,351 |
3,341 |
$699K |
| D1351 |
Sealant - per tooth |
14,639 |
3,405 |
$523K |
| D1206 |
Topical application of fluoride varnish |
20,599 |
20,292 |
$522K |
| D0120 |
Periodic oral evaluation - established patient |
13,251 |
13,063 |
$413K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
7,006 |
6,880 |
$379K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,522 |
1,600 |
$311K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,176 |
1,533 |
$220K |
| D0272 |
Bitewings - two radiographic images |
9,493 |
9,345 |
$154K |
| D0330 |
Panoramic radiographic image |
3,258 |
3,197 |
$144K |
| D9248 |
|
677 |
651 |
$124K |
| D1110 |
Prophylaxis - adult |
1,754 |
1,726 |
$113K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,787 |
5,332 |
$112K |
| D3120 |
|
2,643 |
1,680 |
$91K |
| D0274 |
Bitewings - four radiographic images |
3,284 |
3,232 |
$77K |
| D0140 |
Limited oral evaluation - problem focused |
969 |
955 |
$45K |
| D1330 |
|
6,443 |
6,325 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
3,715 |
3,607 |
$39K |
| D2940 |
|
351 |
208 |
$18K |
| D0240 |
|
1,015 |
998 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
872 |
848 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
37 |
$8K |
| D1510 |
|
93 |
82 |
$8K |
| D2332 |
|
37 |
28 |
$5K |
| D1354 |
|
407 |
159 |
$4K |