| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,643 |
850 |
$158K |
| D1120 |
Prophylaxis - child |
5,745 |
5,594 |
$133K |
| D1206 |
Topical application of fluoride varnish |
7,306 |
7,109 |
$98K |
| D1351 |
Sealant - per tooth |
4,955 |
1,071 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
5,446 |
5,307 |
$84K |
| D1110 |
Prophylaxis - adult |
1,602 |
1,553 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,803 |
1,739 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,407 |
1,366 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,013 |
1,949 |
$31K |
| D9999 |
Unspecified adjunctive procedure, by report |
670 |
651 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
560 |
538 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
191 |
139 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
595 |
576 |
$6K |
| D0240 |
|
355 |
185 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
56 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
168 |
144 |
$3K |
| D0190 |
|
88 |
88 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$816.76 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
13 |
$306.02 |
| D1999 |
|
1,314 |
1,246 |
$0.00 |