| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,509 |
409 |
$177K |
| D1120 |
Prophylaxis - child |
3,051 |
2,815 |
$89K |
| D7962 |
|
260 |
254 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,896 |
2,654 |
$50K |
| D7961 |
|
247 |
242 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
2,003 |
1,845 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,376 |
1,266 |
$40K |
| D1351 |
Sealant - per tooth |
1,663 |
384 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
478 |
191 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,038 |
967 |
$18K |
| D1110 |
Prophylaxis - adult |
353 |
331 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
436 |
411 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
453 |
404 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
334 |
327 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
562 |
513 |
$8K |
| D0330 |
Panoramic radiographic image |
155 |
153 |
$7K |
| D1354 |
|
91 |
45 |
$7K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
17 |
13 |
$3K |
| D0240 |
|
116 |
102 |
$3K |
| D9222 |
|
17 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
95 |
$984.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
51 |
$807.72 |
| D9310 |
|
13 |
13 |
$634.14 |