| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,041 |
324 |
$184K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
832 |
483 |
$113K |
| D2940 |
|
1,887 |
478 |
$97K |
| D7140 |
Extraction, erupted tooth or exposed root |
506 |
242 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,106 |
1,091 |
$61K |
| D1120 |
Prophylaxis - child |
1,146 |
1,137 |
$55K |
| D3120 |
|
1,523 |
497 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
402 |
223 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,630 |
1,621 |
$42K |
| D1351 |
Sealant - per tooth |
986 |
297 |
$39K |
| D2335 |
|
142 |
54 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
362 |
340 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
532 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
791 |
753 |
$15K |
| D0330 |
Panoramic radiographic image |
229 |
229 |
$11K |
| D0272 |
Bitewings - two radiographic images |
541 |
534 |
$9K |
| D2330 |
|
73 |
37 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
505 |
496 |
$6K |
| D1330 |
|
658 |
653 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
176 |
172 |
$2K |
| D0240 |
|
74 |
74 |
$1K |
| D9420 |
|
59 |
59 |
$885.00 |