| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
986 |
263 |
$129K |
| D7140 |
Extraction, erupted tooth or exposed root |
450 |
211 |
$37K |
| D1351 |
Sealant - per tooth |
1,131 |
237 |
$34K |
| D1120 |
Prophylaxis - child |
775 |
773 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,174 |
1,161 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
445 |
436 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
975 |
972 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
129 |
$13K |
| D0272 |
Bitewings - two radiographic images |
702 |
692 |
$12K |
| D1110 |
Prophylaxis - adult |
275 |
274 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
125 |
$10K |
| D0240 |
|
397 |
222 |
$6K |
| D0603 |
|
399 |
399 |
$4K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$4K |
| D1330 |
|
729 |
727 |
$4K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
34 |
$4K |
| D0602 |
|
298 |
297 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
120 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$951.10 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
83 |
$809.49 |
| D1310 |
|
18 |
18 |
$175.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$130.27 |
| D1999 |
|
242 |
235 |
$0.42 |