| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
764 |
215 |
$103K |
| D1120 |
Prophylaxis - child |
1,993 |
1,986 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,074 |
2,060 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,539 |
2,524 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,160 |
1,150 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
186 |
87 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
629 |
551 |
$19K |
| D9420 |
|
118 |
114 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
372 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
859 |
846 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
66 |
$8K |
| D1110 |
Prophylaxis - adult |
164 |
163 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
445 |
388 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
51 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$677.00 |