| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,872 |
936 |
$285K |
| D1120 |
Prophylaxis - child |
7,279 |
7,265 |
$223K |
| D9248 |
|
1,092 |
1,040 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
7,318 |
7,305 |
$151K |
| D1206 |
Topical application of fluoride varnish |
8,332 |
8,317 |
$146K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,742 |
917 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,427 |
886 |
$77K |
| D0272 |
Bitewings - two radiographic images |
3,868 |
3,862 |
$66K |
| D1351 |
Sealant - per tooth |
2,051 |
672 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,329 |
2,328 |
$50K |
| D2390 |
|
341 |
115 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,104 |
1,061 |
$48K |
| D0330 |
Panoramic radiographic image |
749 |
749 |
$32K |
| D1110 |
Prophylaxis - adult |
833 |
831 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
341 |
$31K |
| D9920 |
|
131 |
131 |
$16K |
| D1510 |
|
126 |
82 |
$15K |
| D2330 |
|
238 |
146 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
772 |
764 |
$7K |
| D0240 |
|
519 |
513 |
$7K |
| D2331 |
|
61 |
49 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
152 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$3K |
| D1354 |
|
15 |
13 |
$245.00 |
| D1330 |
|
40,099 |
39,745 |
$33.24 |
| D1310 |
|
40,092 |
39,738 |
$22.74 |
| D9991 |
|
11,918 |
11,901 |
$0.01 |
| D9992 |
|
19,041 |
18,944 |
$0.00 |
| D9994 |
|
5,369 |
5,344 |
$0.00 |
| D9993 |
|
3,483 |
3,348 |
$0.00 |