| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
793 |
267 |
$91K |
| D1120 |
Prophylaxis - child |
1,783 |
1,727 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
950 |
513 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,865 |
1,806 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
720 |
383 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
972 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
448 |
218 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
782 |
748 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
975 |
862 |
$23K |
| D1351 |
Sealant - per tooth |
631 |
257 |
$19K |
| D0272 |
Bitewings - two radiographic images |
729 |
689 |
$16K |
| D0240 |
|
611 |
296 |
$14K |
| D1354 |
|
812 |
181 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
691 |
651 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
717 |
460 |
$10K |
| D0603 |
|
1,070 |
1,021 |
$9K |
| D0274 |
Bitewings - four radiographic images |
98 |
96 |
$4K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$3K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
24 |
$1K |