| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,628 |
459 |
$211K |
| D1120 |
Prophylaxis - child |
2,098 |
2,098 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,358 |
2,358 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,434 |
1,434 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
177 |
$32K |
| D0145 |
Oral evaluation for a patient under three years of age |
488 |
488 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
754 |
752 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
819 |
792 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
593 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
149 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,198 |
1,198 |
$22K |
| D9310 |
|
244 |
243 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
39 |
$11K |
| D1110 |
Prophylaxis - adult |
218 |
218 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
644 |
635 |
$8K |
| D0240 |
|
260 |
183 |
$5K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
81 |
$2K |
| D9222 |
|
12 |
12 |
$1K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
12 |
12 |
$1K |
| D9420 |
|
12 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$420.00 |