| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,595 |
338 |
$256K |
| D1120 |
Prophylaxis - child |
5,010 |
4,628 |
$132K |
| D1206 |
Topical application of fluoride varnish |
5,209 |
4,797 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
4,421 |
4,060 |
$105K |
| D7140 |
Extraction, erupted tooth or exposed root |
833 |
311 |
$82K |
| D1354 |
|
3,071 |
840 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
890 |
500 |
$64K |
| D1351 |
Sealant - per tooth |
1,834 |
558 |
$55K |
| D0272 |
Bitewings - two radiographic images |
2,466 |
2,278 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
920 |
724 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
622 |
567 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
373 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
620 |
573 |
$5K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
17 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
25 |
$321.60 |