| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
805 |
244 |
$89K |
| D1120 |
Prophylaxis - child |
2,336 |
2,336 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,721 |
2,718 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,894 |
1,894 |
$35K |
| D1351 |
Sealant - per tooth |
948 |
266 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
342 |
$9K |
| D0274 |
Bitewings - four radiographic images |
512 |
512 |
$8K |
| D0330 |
Panoramic radiographic image |
312 |
312 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
456 |
$4K |
| D0272 |
Bitewings - two radiographic images |
246 |
246 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$2K |
| D1353 |
|
29 |
12 |
$550.39 |
| D0190 |
|
30 |
30 |
$447.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
101 |
38 |
$398.85 |
| D1354 |
|
81 |
25 |
$339.70 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$337.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$303.29 |