| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,476 |
371 |
$150K |
| D1120 |
Prophylaxis - child |
3,212 |
3,151 |
$62K |
| D1206 |
Topical application of fluoride varnish |
3,241 |
3,174 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
2,180 |
2,163 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
502 |
247 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,028 |
979 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,588 |
1,563 |
$15K |
| D1351 |
Sealant - per tooth |
695 |
206 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
504 |
492 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
129 |
$10K |
| D1354 |
|
349 |
129 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
412 |
404 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
73 |
69 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$510.00 |