| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
551 |
214 |
$75K |
| D1351 |
Sealant - per tooth |
2,400 |
388 |
$73K |
| D1120 |
Prophylaxis - child |
1,867 |
1,860 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,966 |
1,958 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,337 |
1,337 |
$43K |
| D0272 |
Bitewings - two radiographic images |
922 |
922 |
$27K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
342 |
209 |
$25K |
| D0330 |
Panoramic radiographic image |
319 |
318 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
632 |
632 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
261 |
168 |
$21K |
| D0240 |
|
455 |
253 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
116 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
71 |
$8K |
| D1110 |
Prophylaxis - adult |
274 |
273 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
187 |
$8K |
| D2330 |
|
112 |
50 |
$7K |
| D2140 |
|
106 |
71 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
346 |
336 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
85 |
85 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
220 |
$4K |
| D2331 |
|
34 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
24 |
$614.70 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$403.91 |