| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,484 |
914 |
$543K |
| D0120 |
Periodic oral evaluation - established patient |
15,985 |
15,725 |
$473K |
| D1110 |
Prophylaxis - adult |
7,489 |
7,362 |
$455K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,641 |
2,529 |
$448K |
| D1120 |
Prophylaxis - child |
9,143 |
8,996 |
$399K |
| D1206 |
Topical application of fluoride varnish |
14,049 |
13,830 |
$348K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,249 |
1,542 |
$214K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,936 |
689 |
$199K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,731 |
1,704 |
$90K |
| D0274 |
Bitewings - four radiographic images |
3,703 |
3,638 |
$83K |
| D0272 |
Bitewings - two radiographic images |
3,224 |
3,169 |
$49K |
| D0330 |
Panoramic radiographic image |
1,097 |
1,082 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,202 |
1,912 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
187 |
149 |
$30K |
| D1330 |
|
3,723 |
3,663 |
$23K |
| D1351 |
Sealant - per tooth |
621 |
240 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,245 |
1,208 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
619 |
603 |
$10K |
| D0240 |
|
590 |
578 |
$9K |
| D3120 |
|
468 |
167 |
$7K |
| D2330 |
|
51 |
26 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
92 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
105 |
$2K |