| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,238 |
401 |
$156K |
| D1120 |
Prophylaxis - child |
2,554 |
2,462 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
641 |
280 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,362 |
1,305 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,565 |
2,467 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,443 |
1,398 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
776 |
669 |
$35K |
| D1351 |
Sealant - per tooth |
956 |
300 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,102 |
1,045 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
192 |
84 |
$12K |
| D0330 |
Panoramic radiographic image |
219 |
203 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
635 |
547 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
577 |
234 |
$7K |
| D0240 |
|
288 |
234 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
27 |
$3K |
| D1354 |
|
157 |
54 |
$1K |