| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
813 |
173 |
$164K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,229 |
1,213 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
293 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,818 |
1,783 |
$49K |
| D1351 |
Sealant - per tooth |
1,386 |
362 |
$41K |
| D1120 |
Prophylaxis - child |
1,422 |
1,410 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
208 |
$30K |
| D9999 |
Unspecified adjunctive procedure, by report |
760 |
752 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
756 |
751 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
336 |
156 |
$19K |
| D2929 |
|
62 |
16 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
650 |
592 |
$15K |
| D9248 |
|
204 |
191 |
$14K |
| D0330 |
Panoramic radiographic image |
313 |
309 |
$12K |
| D0272 |
Bitewings - two radiographic images |
994 |
976 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
947 |
891 |
$8K |
| D0240 |
|
778 |
467 |
$7K |
| D9630 |
|
84 |
84 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,621 |
588 |
$4K |
| D1110 |
Prophylaxis - adult |
81 |
80 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
117 |
$3K |
| D0274 |
Bitewings - four radiographic images |
166 |
163 |
$2K |