| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
783 |
246 |
$79K |
| D1120 |
Prophylaxis - child |
1,373 |
1,367 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,425 |
1,417 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,028 |
1,024 |
$17K |
| D0240 |
|
930 |
532 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,120 |
755 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
376 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
57 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
947 |
930 |
$5K |
| D1510 |
|
38 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
287 |
287 |
$3K |
| D1351 |
Sealant - per tooth |
128 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
442 |
413 |
$0.00 |