| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,265 |
406 |
$192K |
| D1120 |
Prophylaxis - child |
3,478 |
3,288 |
$132K |
| D1206 |
Topical application of fluoride varnish |
4,405 |
4,167 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,691 |
3,469 |
$91K |
| D1351 |
Sealant - per tooth |
2,004 |
447 |
$57K |
| D1110 |
Prophylaxis - adult |
958 |
909 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,419 |
1,360 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
751 |
726 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
906 |
826 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
231 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
207 |
114 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
474 |
438 |
$13K |
| D0274 |
Bitewings - four radiographic images |
337 |
313 |
$11K |
| D1354 |
|
185 |
62 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
116 |
$8K |
| D0240 |
|
485 |
225 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
85 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
138 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
39 |
$2K |