| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,767 |
400 |
$207K |
| D1120 |
Prophylaxis - child |
1,436 |
1,338 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
539 |
238 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,408 |
1,306 |
$25K |
| D9310 |
|
418 |
398 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
846 |
786 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
411 |
$13K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
52 |
52 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
356 |
330 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
705 |
641 |
$11K |
| D1354 |
|
142 |
62 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
389 |
363 |
$10K |
| D0272 |
Bitewings - two radiographic images |
553 |
516 |
$10K |
| D1351 |
Sealant - per tooth |
207 |
77 |
$5K |
| D9222 |
|
52 |
52 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
370 |
262 |
$3K |
| D9610 |
|
52 |
52 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$975.68 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$731.70 |