| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,325 |
346 |
$419K |
| D1120 |
Prophylaxis - child |
4,652 |
4,350 |
$267K |
| D0120 |
Periodic oral evaluation - established patient |
3,741 |
3,498 |
$161K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,218 |
320 |
$147K |
| D1351 |
Sealant - per tooth |
3,107 |
794 |
$133K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,479 |
4,177 |
$117K |
| D0272 |
Bitewings - two radiographic images |
1,914 |
1,783 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,204 |
1,079 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
706 |
660 |
$42K |
| D0240 |
|
946 |
470 |
$27K |
| D9420 |
|
297 |
252 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
67 |
$16K |
| D0330 |
Panoramic radiographic image |
156 |
143 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
43 |
$11K |
| D1206 |
Topical application of fluoride varnish |
386 |
365 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
471 |
179 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
380 |
$9K |
| D2330 |
|
52 |
32 |
$6K |
| D2331 |
|
24 |
14 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
21 |
16 |
$904.05 |