| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,604 |
557 |
$337K |
| D1120 |
Prophylaxis - child |
5,939 |
5,932 |
$182K |
| D1206 |
Topical application of fluoride varnish |
6,698 |
6,545 |
$180K |
| D0120 |
Periodic oral evaluation - established patient |
5,349 |
5,344 |
$139K |
| D1999 |
|
3,788 |
3,652 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,010 |
940 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,976 |
1,521 |
$30K |
| D9420 |
|
254 |
253 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,781 |
1,780 |
$23K |
| D1351 |
Sealant - per tooth |
803 |
241 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
814 |
813 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,160 |
2,123 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
585 |
584 |
$14K |
| D1110 |
Prophylaxis - adult |
237 |
237 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
80 |
$8K |
| D0330 |
Panoramic radiographic image |
302 |
302 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
160 |
160 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| D0170 |
|
117 |
117 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$786.10 |