| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,045 |
1,684 |
$468K |
| D1351 |
Sealant - per tooth |
16,927 |
3,236 |
$363K |
| D0120 |
Periodic oral evaluation - established patient |
18,907 |
17,777 |
$344K |
| D1120 |
Prophylaxis - child |
11,651 |
10,956 |
$319K |
| D1206 |
Topical application of fluoride varnish |
18,528 |
17,387 |
$312K |
| D1110 |
Prophylaxis - adult |
6,347 |
5,932 |
$233K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,764 |
2,217 |
$158K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,352 |
1,128 |
$145K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,696 |
4,947 |
$138K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,554 |
1,630 |
$138K |
| D0272 |
Bitewings - two radiographic images |
6,414 |
6,004 |
$118K |
| D0274 |
Bitewings - four radiographic images |
2,974 |
2,754 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
2,264 |
1,941 |
$76K |
| D0330 |
Panoramic radiographic image |
1,906 |
1,731 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,391 |
2,241 |
$66K |
| D0240 |
|
3,638 |
1,604 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
752 |
684 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
763 |
686 |
$7K |
| D2330 |
|
84 |
51 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
53 |
$2K |