| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,692 |
433 |
$226K |
| D1120 |
Prophylaxis - child |
3,654 |
3,541 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
843 |
495 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
3,184 |
3,088 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,930 |
2,833 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
692 |
331 |
$40K |
| D1351 |
Sealant - per tooth |
1,504 |
437 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
525 |
316 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
960 |
854 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
862 |
819 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
574 |
542 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,188 |
1,141 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,402 |
601 |
$14K |
| D1206 |
Topical application of fluoride varnish |
930 |
904 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
962 |
891 |
$13K |
| D1110 |
Prophylaxis - adult |
189 |
184 |
$7K |
| D0330 |
Panoramic radiographic image |
56 |
55 |
$3K |
| D1354 |
|
36 |
18 |
$165.00 |