| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,277 |
224 |
$180K |
| D1120 |
Prophylaxis - child |
1,619 |
1,549 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,556 |
1,495 |
$39K |
| D1351 |
Sealant - per tooth |
1,207 |
193 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
386 |
164 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
674 |
649 |
$30K |
| D0350 |
|
878 |
855 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
590 |
586 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,736 |
999 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,204 |
1,105 |
$15K |
| D0272 |
Bitewings - two radiographic images |
778 |
761 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
295 |
291 |
$13K |
| D2934 |
|
61 |
16 |
$12K |
| D0330 |
Panoramic radiographic image |
263 |
260 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$1K |
| D1330 |
|
1,671 |
1,495 |
$0.00 |
| D1310 |
|
1,668 |
1,491 |
$0.00 |