| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,307 |
447 |
$240K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,349 |
489 |
$114K |
| D1120 |
Prophylaxis - child |
3,359 |
3,324 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
4,644 |
4,588 |
$99K |
| D1206 |
Topical application of fluoride varnish |
4,824 |
4,754 |
$87K |
| D1110 |
Prophylaxis - adult |
1,793 |
1,784 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
669 |
427 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,081 |
1,028 |
$58K |
| D9420 |
|
190 |
187 |
$45K |
| D1351 |
Sealant - per tooth |
1,626 |
487 |
$41K |
| D0272 |
Bitewings - two radiographic images |
2,030 |
2,004 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
959 |
942 |
$27K |
| D0240 |
|
1,012 |
612 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
156 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
175 |
133 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
529 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
446 |
197 |
$8K |
| D1354 |
|
280 |
110 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$2K |