| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,981 |
794 |
$330K |
| D0120 |
Periodic oral evaluation - established patient |
5,490 |
5,395 |
$129K |
| D1120 |
Prophylaxis - child |
5,288 |
5,193 |
$115K |
| D1206 |
Topical application of fluoride varnish |
5,613 |
5,513 |
$91K |
| D1351 |
Sealant - per tooth |
3,476 |
907 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
850 |
372 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,907 |
2,813 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,466 |
1,411 |
$27K |
| D9999 |
Unspecified adjunctive procedure, by report |
793 |
774 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
349 |
182 |
$19K |
| D0240 |
|
1,766 |
849 |
$13K |
| D0330 |
Panoramic radiographic image |
261 |
252 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
132 |
$10K |
| D1110 |
Prophylaxis - adult |
129 |
127 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
382 |
366 |
$3K |
| D9248 |
|
53 |
50 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
131 |
130 |
$2K |
| D1354 |
|
323 |
124 |
$930.00 |
| D9995 |
|
14 |
12 |
$110.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$49.77 |