| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
391 |
113 |
$70K |
| D1120 |
Prophylaxis - child |
2,058 |
1,982 |
$68K |
| D1354 |
|
2,503 |
651 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,353 |
2,259 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
681 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,217 |
1,174 |
$30K |
| D1351 |
Sealant - per tooth |
1,232 |
323 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
255 |
106 |
$24K |
| D0274 |
Bitewings - four radiographic images |
741 |
713 |
$22K |
| D1110 |
Prophylaxis - adult |
394 |
375 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
340 |
316 |
$15K |
| D0330 |
Panoramic radiographic image |
274 |
265 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
112 |
$11K |
| D0272 |
Bitewings - two radiographic images |
350 |
338 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
147 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
42 |
$6K |
| D0240 |
|
391 |
199 |
$5K |
| D1330 |
|
136 |
127 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
131 |
$2K |
| D2940 |
|
32 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
25 |
$351.00 |
| D0603 |
|
82 |
76 |
$0.00 |