| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,284 |
475 |
$162K |
| D1120 |
Prophylaxis - child |
2,249 |
2,075 |
$79K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,034 |
506 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,669 |
2,466 |
$57K |
| D1354 |
|
668 |
149 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,834 |
1,684 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,465 |
1,193 |
$41K |
| D1351 |
Sealant - per tooth |
1,034 |
297 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
654 |
591 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
686 |
632 |
$23K |
| D1110 |
Prophylaxis - adult |
352 |
322 |
$18K |
| D0272 |
Bitewings - two radiographic images |
627 |
570 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
116 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
617 |
534 |
$6K |
| D0330 |
Panoramic radiographic image |
95 |
92 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
53 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
503 |
211 |
$4K |
| D1510 |
|
21 |
12 |
$3K |
| D0240 |
|
176 |
81 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
36 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
39 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$351.29 |