| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,452 |
754 |
$128K |
| D1120 |
Prophylaxis - child |
5,023 |
4,818 |
$109K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,696 |
5,353 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,532 |
946 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,601 |
1,540 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
4,060 |
3,906 |
$49K |
| D9920 |
|
459 |
438 |
$36K |
| D2390 |
|
262 |
70 |
$36K |
| D1110 |
Prophylaxis - adult |
670 |
658 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
911 |
601 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
324 |
319 |
$23K |
| D9310 |
|
533 |
528 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,275 |
685 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,395 |
1,315 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,133 |
2,000 |
$16K |
| D1206 |
Topical application of fluoride varnish |
3,212 |
3,200 |
$10K |
| D1351 |
Sealant - per tooth |
1,778 |
755 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
6,249 |
5,954 |
$3K |
| D1510 |
|
30 |
14 |
$3K |
| D1330 |
|
5,552 |
5,352 |
$3K |
| D0272 |
Bitewings - two radiographic images |
771 |
736 |
$700.92 |
| D0274 |
Bitewings - four radiographic images |
406 |
400 |
$668.83 |
| D1354 |
|
427 |
170 |
$535.53 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,277 |
2,074 |
$326.90 |
| D3120 |
|
206 |
158 |
$155.52 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$44.79 |
| D0350 |
|
64 |
62 |
$41.80 |