| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,554 |
1,297 |
$497K |
| D1120 |
Prophylaxis - child |
12,232 |
11,768 |
$332K |
| D0120 |
Periodic oral evaluation - established patient |
10,188 |
9,915 |
$266K |
| D1206 |
Topical application of fluoride varnish |
14,134 |
13,614 |
$227K |
| D1351 |
Sealant - per tooth |
7,844 |
2,178 |
$222K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,656 |
2,450 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,454 |
2,308 |
$105K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,426 |
789 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,281 |
2,588 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
769 |
598 |
$81K |
| D0330 |
Panoramic radiographic image |
1,376 |
1,329 |
$78K |
| D0272 |
Bitewings - two radiographic images |
4,181 |
4,033 |
$76K |
| D1110 |
Prophylaxis - adult |
1,966 |
1,909 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
877 |
594 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
4,428 |
4,235 |
$66K |
| D0140 |
Limited oral evaluation - problem focused |
1,649 |
1,568 |
$60K |
| D0240 |
|
3,505 |
1,982 |
$57K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,608 |
1,442 |
$52K |
| D0274 |
Bitewings - four radiographic images |
598 |
585 |
$19K |
| D9420 |
|
113 |
105 |
$13K |
| D2934 |
|
33 |
12 |
$4K |