| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,372 |
884 |
$607K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,128 |
1,117 |
$158K |
| D1120 |
Prophylaxis - child |
3,577 |
3,536 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
4,397 |
4,337 |
$124K |
| D0272 |
Bitewings - two radiographic images |
2,848 |
2,751 |
$60K |
| D1206 |
Topical application of fluoride varnish |
4,069 |
4,027 |
$59K |
| D1351 |
Sealant - per tooth |
2,251 |
753 |
$59K |
| D9248 |
|
443 |
436 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,282 |
1,260 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,162 |
1,155 |
$38K |
| D1110 |
Prophylaxis - adult |
681 |
674 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,901 |
1,788 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
270 |
174 |
$21K |
| D0330 |
Panoramic radiographic image |
313 |
312 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,147 |
652 |
$9K |
| D9420 |
|
266 |
256 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
57 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
65 |
$6K |
| D9430 |
|
261 |
258 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
39 |
$948.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$808.50 |
| D0603 |
|
6,778 |
6,694 |
$0.00 |