| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
364 |
72 |
$51K |
| D1120 |
Prophylaxis - child |
1,596 |
1,502 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,779 |
1,682 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
289 |
166 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,966 |
1,858 |
$34K |
| D1351 |
Sealant - per tooth |
789 |
264 |
$27K |
| D1110 |
Prophylaxis - adult |
527 |
501 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
109 |
$19K |
| D0272 |
Bitewings - two radiographic images |
777 |
738 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,255 |
1,181 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
156 |
79 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,118 |
1,046 |
$15K |
| D3120 |
|
323 |
61 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
317 |
279 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
235 |
$10K |
| D0240 |
|
237 |
221 |
$9K |
| D0274 |
Bitewings - four radiographic images |
274 |
264 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
246 |
236 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
147 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
58 |
58 |
$2K |
| D0350 |
|
17 |
12 |
$577.02 |