| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
851 |
228 |
$122K |
| D1120 |
Prophylaxis - child |
3,858 |
3,743 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
2,710 |
2,649 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,561 |
1,483 |
$68K |
| D1206 |
Topical application of fluoride varnish |
4,074 |
3,945 |
$66K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,294 |
1,159 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
507 |
280 |
$53K |
| D1351 |
Sealant - per tooth |
1,911 |
579 |
$48K |
| D0240 |
|
1,854 |
1,026 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,396 |
1,083 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
442 |
210 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,668 |
1,599 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,443 |
1,384 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
199 |
126 |
$15K |
| D0330 |
Panoramic radiographic image |
239 |
235 |
$10K |
| D1354 |
|
1,597 |
487 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
178 |
$7K |
| D9420 |
|
38 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
57 |
55 |
$2K |
| D9248 |
|
17 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
36 |
35 |
$603.90 |