| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
366 |
215 |
$70K |
| D1206 |
Topical application of fluoride varnish |
2,072 |
1,997 |
$61K |
| D1120 |
Prophylaxis - child |
1,423 |
1,357 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,692 |
1,625 |
$52K |
| D0330 |
Panoramic radiographic image |
492 |
485 |
$39K |
| D1110 |
Prophylaxis - adult |
585 |
575 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,058 |
1,004 |
$30K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
205 |
168 |
$20K |
| D0274 |
Bitewings - four radiographic images |
535 |
530 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
315 |
$15K |
| D1351 |
Sealant - per tooth |
393 |
117 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
565 |
391 |
$12K |
| D2140 |
|
143 |
113 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
81 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
488 |
477 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
51 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
143 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
74 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
15 |
$2K |
| D0240 |
|
85 |
55 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$710.00 |