| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
650 |
213 |
$121K |
| D1120 |
Prophylaxis - child |
4,033 |
3,935 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,666 |
2,628 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
741 |
368 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,248 |
1,201 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,805 |
1,763 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,301 |
1,268 |
$33K |
| D1351 |
Sealant - per tooth |
1,205 |
401 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
478 |
260 |
$27K |
| D9999 |
Unspecified adjunctive procedure, by report |
698 |
694 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
868 |
756 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,585 |
1,541 |
$15K |
| D0240 |
|
1,610 |
802 |
$13K |
| D9630 |
|
354 |
345 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
280 |
273 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
803 |
737 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
54 |
$6K |
| D1354 |
|
1,343 |
401 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
921 |
352 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$510.60 |
| D1999 |
|
46 |
42 |
$267.00 |