| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,165 |
316 |
$223K |
| D1351 |
Sealant - per tooth |
4,159 |
875 |
$137K |
| D1120 |
Prophylaxis - child |
3,022 |
3,022 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
3,345 |
3,345 |
$109K |
| D1206 |
Topical application of fluoride varnish |
3,824 |
3,824 |
$105K |
| D0272 |
Bitewings - two radiographic images |
1,717 |
1,717 |
$42K |
| D1354 |
|
1,316 |
399 |
$36K |
| D1110 |
Prophylaxis - adult |
720 |
720 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
193 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
333 |
234 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
133 |
$21K |
| D9420 |
|
101 |
101 |
$16K |
| D0240 |
|
682 |
357 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
172 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
353 |
351 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$6K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$1K |
| D9248 |
|
62 |
57 |
$960.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
61 |
$0.00 |