| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,300 |
766 |
$274K |
| D1120 |
Prophylaxis - child |
7,098 |
6,533 |
$174K |
| D0120 |
Periodic oral evaluation - established patient |
7,303 |
6,830 |
$128K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,440 |
5,995 |
$81K |
| D1999 |
|
3,953 |
3,797 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,796 |
2,583 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,704 |
2,496 |
$43K |
| D1354 |
|
966 |
260 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,192 |
1,076 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
512 |
201 |
$22K |
| D0330 |
Panoramic radiographic image |
513 |
464 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
495 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
439 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
410 |
406 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
438 |
404 |
$4K |
| D1351 |
Sealant - per tooth |
186 |
37 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
24 |
$1K |
| D1110 |
Prophylaxis - adult |
34 |
31 |
$1K |
| D9310 |
|
281 |
266 |
$799.28 |
| D9995 |
|
15 |
14 |
$0.00 |
| D9420 |
|
16 |
13 |
$0.00 |
| D1330 |
|
18 |
17 |
$0.00 |
| D9430 |
|
12 |
12 |
$0.00 |