| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,630 |
669 |
$156K |
| D1120 |
Prophylaxis - child |
3,638 |
3,545 |
$82K |
| D1351 |
Sealant - per tooth |
3,741 |
830 |
$67K |
| D1206 |
Topical application of fluoride varnish |
4,942 |
4,800 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
3,384 |
3,307 |
$51K |
| D1110 |
Prophylaxis - adult |
916 |
881 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,093 |
1,041 |
$23K |
| D0274 |
Bitewings - four radiographic images |
922 |
890 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,267 |
1,236 |
$19K |
| D9999 |
Unspecified adjunctive procedure, by report |
518 |
500 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
461 |
458 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
231 |
142 |
$11K |
| D0190 |
|
474 |
466 |
$6K |
| D0240 |
|
425 |
235 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
522 |
507 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
97 |
84 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
52 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$646.16 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$329.56 |
| D1999 |
|
1,217 |
1,157 |
$0.00 |
| D9920 |
|
13 |
13 |
$0.00 |