| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,508 |
476 |
$232K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,410 |
676 |
$169K |
| D1120 |
Prophylaxis - child |
3,547 |
3,503 |
$150K |
| D1206 |
Topical application of fluoride varnish |
4,287 |
4,231 |
$107K |
| D1351 |
Sealant - per tooth |
3,213 |
805 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
984 |
545 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,641 |
2,604 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
708 |
398 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,321 |
1,309 |
$68K |
| D3120 |
|
1,698 |
591 |
$59K |
| D2940 |
|
1,022 |
335 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,489 |
1,374 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,476 |
1,455 |
$22K |
| D0330 |
Panoramic radiographic image |
374 |
368 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
274 |
265 |
$12K |
| D1110 |
Prophylaxis - adult |
186 |
184 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
488 |
477 |
$4K |
| D0240 |
|
329 |
325 |
$4K |
| D2330 |
|
36 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
81 |
78 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
206 |
$2K |
| D1330 |
|
25 |
25 |
$150.00 |