| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,137 |
213 |
$198K |
| D1120 |
Prophylaxis - child |
2,691 |
2,518 |
$106K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,679 |
2,508 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,810 |
1,694 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
374 |
192 |
$34K |
| D0272 |
Bitewings - two radiographic images |
775 |
730 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
172 |
73 |
$19K |
| D0330 |
Panoramic radiographic image |
229 |
221 |
$16K |
| D0274 |
Bitewings - four radiographic images |
366 |
339 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
259 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
313 |
297 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
90 |
$11K |
| D8670 |
Periodic orthodontic treatment visit |
89 |
89 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
75 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
20 |
$1K |
| D1110 |
Prophylaxis - adult |
40 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
27 |
$449.82 |