| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
978 |
327 |
$248K |
| D1120 |
Prophylaxis - child |
3,326 |
3,306 |
$178K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,001 |
1,704 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
3,496 |
3,475 |
$131K |
| D1206 |
Topical application of fluoride varnish |
3,928 |
3,904 |
$126K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
695 |
512 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
669 |
302 |
$98K |
| D0272 |
Bitewings - two radiographic images |
2,111 |
2,097 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
359 |
283 |
$41K |
| D1351 |
Sealant - per tooth |
854 |
336 |
$40K |
| D1110 |
Prophylaxis - adult |
468 |
467 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
496 |
$30K |
| D0330 |
Panoramic radiographic image |
171 |
170 |
$15K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
13 |
$7K |
| D0240 |
|
142 |
132 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$1K |
| D1354 |
|
23 |
13 |
$550.00 |