| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,211 |
1,787 |
$652K |
| D1120 |
Prophylaxis - child |
17,363 |
15,438 |
$486K |
| D0120 |
Periodic oral evaluation - established patient |
22,433 |
19,914 |
$419K |
| D1351 |
Sealant - per tooth |
15,061 |
2,323 |
$350K |
| D1206 |
Topical application of fluoride varnish |
17,328 |
15,591 |
$349K |
| D1110 |
Prophylaxis - adult |
7,124 |
6,305 |
$270K |
| D0272 |
Bitewings - two radiographic images |
11,596 |
10,204 |
$233K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,797 |
1,259 |
$175K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,259 |
4,491 |
$131K |
| D0330 |
Panoramic radiographic image |
2,425 |
2,118 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,955 |
1,315 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,587 |
6,525 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,263 |
2,886 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,974 |
1,397 |
$79K |
| D0140 |
Limited oral evaluation - problem focused |
968 |
838 |
$28K |
| D1354 |
|
378 |
146 |
$19K |
| D0240 |
|
572 |
481 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,344 |
1,062 |
$9K |
| D2330 |
|
131 |
77 |
$9K |
| D0274 |
Bitewings - four radiographic images |
193 |
149 |
$6K |
| D1999 |
|
2,348 |
2,089 |
$830.00 |
| D9920 |
|
17 |
12 |
$467.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
13 |
$166.00 |
| D1353 |
|
122 |
30 |
$0.00 |