| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,625 |
1,145 |
$679K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,086 |
1,067 |
$266K |
| D1120 |
Prophylaxis - child |
5,973 |
5,748 |
$214K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,709 |
1,256 |
$183K |
| D1351 |
Sealant - per tooth |
6,403 |
1,626 |
$165K |
| D1206 |
Topical application of fluoride varnish |
7,692 |
7,280 |
$160K |
| D1310 |
|
3,639 |
3,509 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
4,689 |
4,502 |
$119K |
| D1354 |
|
5,491 |
1,157 |
$114K |
| D9248 |
|
716 |
667 |
$100K |
| D1330 |
|
3,634 |
3,502 |
$96K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,131 |
480 |
$80K |
| D0350 |
|
2,106 |
1,949 |
$66K |
| D2330 |
|
1,058 |
432 |
$64K |
| D3120 |
|
2,093 |
836 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
1,730 |
1,528 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,397 |
2,263 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,515 |
1,397 |
$45K |
| D0603 |
|
3,534 |
3,401 |
$41K |
| D0240 |
|
1,871 |
938 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,768 |
1,124 |
$29K |
| D0145 |
Oral evaluation for a patient under three years of age |
702 |
691 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,592 |
1,424 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
661 |
637 |
$23K |
| D0425 |
|
432 |
421 |
$21K |
| D9630 |
|
1,154 |
1,081 |
$18K |
| D1110 |
Prophylaxis - adult |
310 |
300 |
$16K |
| D2331 |
|
100 |
59 |
$10K |
| D0330 |
Panoramic radiographic image |
146 |
136 |
$8K |
| D9920 |
|
59 |
57 |
$3K |
| D1999 |
|
3,581 |
3,197 |
$3K |
| D9310 |
|
34 |
27 |
$1K |
| D1320 |
|
42 |
39 |
$1K |
| D1353 |
|
28 |
14 |
$662.50 |
| D1352 |
|
19 |
13 |
$553.44 |