| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,774 |
640 |
$296K |
| D1120 |
Prophylaxis - child |
3,767 |
3,717 |
$169K |
| D7140 |
Extraction, erupted tooth or exposed root |
984 |
513 |
$115K |
| D1206 |
Topical application of fluoride varnish |
4,423 |
4,361 |
$111K |
| D1351 |
Sealant - per tooth |
2,941 |
869 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
2,958 |
2,920 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
351 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,345 |
1,320 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,670 |
2,068 |
$50K |
| D3120 |
|
1,287 |
516 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,669 |
1,635 |
$26K |
| D0330 |
Panoramic radiographic image |
486 |
478 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
108 |
$14K |
| D1330 |
|
2,039 |
2,013 |
$13K |
| D0240 |
|
672 |
654 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
705 |
659 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
126 |
$6K |
| D1110 |
Prophylaxis - adult |
45 |
44 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
111 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
68 |
$2K |
| D9420 |
|
16 |
16 |
$240.00 |