| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,680 |
348 |
$199K |
| D1206 |
Topical application of fluoride varnish |
8,150 |
7,853 |
$187K |
| D1120 |
Prophylaxis - child |
7,132 |
7,114 |
$181K |
| D0120 |
Periodic oral evaluation - established patient |
6,356 |
6,354 |
$141K |
| D1351 |
Sealant - per tooth |
2,789 |
835 |
$69K |
| D0272 |
Bitewings - two radiographic images |
5,138 |
5,131 |
$64K |
| D1999 |
|
2,903 |
2,872 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
472 |
305 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
886 |
858 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
940 |
927 |
$21K |
| D9420 |
|
185 |
185 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
77 |
$10K |
| D0274 |
Bitewings - four radiographic images |
538 |
538 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
401 |
401 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,389 |
1,373 |
$8K |
| D2934 |
|
58 |
14 |
$8K |
| D1110 |
Prophylaxis - adult |
181 |
181 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
778 |
685 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$500.37 |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$337.05 |