| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,268 |
251 |
$202K |
| D9310 |
|
403 |
396 |
$43K |
| D1120 |
Prophylaxis - child |
1,113 |
1,087 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
308 |
110 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
1,058 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,195 |
1,164 |
$20K |
| D0272 |
Bitewings - two radiographic images |
860 |
834 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
88 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
39 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
478 |
450 |
$7K |
| D9420 |
|
41 |
39 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
142 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
16 |
$464.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
13 |
$320.00 |