| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,030 |
281 |
$70K |
| D1120 |
Prophylaxis - child |
2,708 |
2,436 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,212 |
2,868 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
2,803 |
2,522 |
$34K |
| D1110 |
Prophylaxis - adult |
1,114 |
1,010 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,389 |
1,235 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
678 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
803 |
677 |
$14K |
| D2140 |
|
268 |
155 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
458 |
385 |
$11K |
| D0274 |
Bitewings - four radiographic images |
411 |
374 |
$8K |
| D1351 |
Sealant - per tooth |
502 |
132 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
187 |
103 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
76 |
46 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
427 |
375 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
185 |
$2K |
| D0330 |
Panoramic radiographic image |
95 |
78 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
40 |
$479.20 |
| D0270 |
|
49 |
45 |
$138.32 |