| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
581 |
120 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
579 |
269 |
$135K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
426 |
220 |
$82K |
| D1120 |
Prophylaxis - child |
1,709 |
1,521 |
$82K |
| D1351 |
Sealant - per tooth |
2,231 |
450 |
$73K |
| D0240 |
|
2,133 |
973 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,034 |
923 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,855 |
1,653 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
296 |
84 |
$48K |
| D0330 |
Panoramic radiographic image |
469 |
416 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
451 |
397 |
$32K |
| D0160 |
|
482 |
355 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
629 |
$26K |
| D0272 |
Bitewings - two radiographic images |
762 |
652 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
799 |
271 |
$15K |
| D1354 |
|
220 |
83 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
532 |
381 |
$11K |
| D1110 |
Prophylaxis - adult |
101 |
97 |
$6K |
| D0274 |
Bitewings - four radiographic images |
92 |
89 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
63 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$937.57 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$746.64 |
| D0603 |
|
2,235 |
1,931 |
$0.00 |
| D0602 |
|
24 |
24 |
$0.00 |