| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,016 |
1,953 |
$54K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
284 |
146 |
$54K |
| D1120 |
Prophylaxis - child |
1,459 |
1,410 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,742 |
1,688 |
$49K |
| D1351 |
Sealant - per tooth |
1,178 |
404 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
326 |
$34K |
| D0330 |
Panoramic radiographic image |
412 |
387 |
$33K |
| D1110 |
Prophylaxis - adult |
570 |
555 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,010 |
994 |
$26K |
| D0274 |
Bitewings - four radiographic images |
560 |
548 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
142 |
$17K |
| D2140 |
|
160 |
111 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
123 |
92 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
434 |
335 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
526 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
141 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
24 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
23 |
16 |
$800.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$800.00 |