| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,860 |
695 |
$525K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,935 |
868 |
$187K |
| D1120 |
Prophylaxis - child |
4,176 |
4,169 |
$185K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,499 |
548 |
$161K |
| D1206 |
Topical application of fluoride varnish |
3,659 |
3,653 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
2,003 |
2,002 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,477 |
1,477 |
$89K |
| D0140 |
Limited oral evaluation - problem focused |
1,473 |
1,454 |
$83K |
| D0272 |
Bitewings - two radiographic images |
1,804 |
1,800 |
$73K |
| D1510 |
|
293 |
173 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
664 |
359 |
$51K |
| D0240 |
|
1,189 |
618 |
$49K |
| D1351 |
Sealant - per tooth |
1,146 |
400 |
$46K |
| D0330 |
Panoramic radiographic image |
307 |
307 |
$33K |
| D2330 |
|
294 |
124 |
$26K |
| D1330 |
|
683 |
683 |
$25K |
| D2332 |
|
146 |
72 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
578 |
529 |
$12K |
| D1354 |
|
385 |
153 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
461 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
185 |
185 |
$11K |
| D1310 |
|
281 |
281 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
170 |
$5K |
| D2331 |
|
41 |
27 |
$5K |
| D9420 |
|
529 |
520 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$831.72 |