| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
694 |
318 |
$134K |
| D7140 |
Extraction, erupted tooth or exposed root |
672 |
359 |
$74K |
| D1120 |
Prophylaxis - child |
1,342 |
1,339 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,495 |
1,491 |
$54K |
| D1351 |
Sealant - per tooth |
1,286 |
416 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
518 |
516 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
841 |
840 |
$31K |
| D0272 |
Bitewings - two radiographic images |
872 |
871 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
173 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,164 |
1,150 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,045 |
923 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
165 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
353 |
346 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
109 |
$7K |
| D0274 |
Bitewings - four radiographic images |
161 |
160 |
$7K |
| D0330 |
Panoramic radiographic image |
41 |
40 |
$4K |
| D3120 |
|
45 |
31 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$842.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$779.24 |
| D9996 |
|
17 |
17 |
$238.00 |