| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,124 |
279 |
$141K |
| D7140 |
Extraction, erupted tooth or exposed root |
686 |
297 |
$68K |
| D1120 |
Prophylaxis - child |
2,043 |
1,973 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,613 |
2,513 |
$58K |
| D1206 |
Topical application of fluoride varnish |
3,170 |
3,053 |
$53K |
| D1351 |
Sealant - per tooth |
1,154 |
350 |
$39K |
| D1110 |
Prophylaxis - adult |
880 |
852 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
166 |
$26K |
| D9420 |
|
196 |
192 |
$22K |
| D0272 |
Bitewings - two radiographic images |
956 |
923 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
512 |
485 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
358 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
438 |
418 |
$13K |
| D0274 |
Bitewings - four radiographic images |
393 |
383 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
870 |
822 |
$11K |
| D0330 |
Panoramic radiographic image |
195 |
184 |
$10K |
| D0240 |
|
315 |
299 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
218 |
211 |
$7K |
| D2934 |
|
40 |
13 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
162 |
162 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
28 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
214 |
204 |
$3K |
| D1353 |
|
60 |
27 |
$2K |
| D3120 |
|
25 |
12 |
$965.84 |