| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
324 |
99 |
$37K |
| D1120 |
Prophylaxis - child |
814 |
812 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
633 |
631 |
$20K |
| D1206 |
Topical application of fluoride varnish |
774 |
772 |
$16K |
| D1351 |
Sealant - per tooth |
316 |
91 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
78 |
$10K |
| D0272 |
Bitewings - two radiographic images |
381 |
379 |
$8K |
| D0603 |
|
840 |
837 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
653 |
231 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
31 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$5K |
| D0240 |
|
269 |
167 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
309 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
160 |
152 |
$5K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
27 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
79 |
79 |
$2K |
| D9248 |
|
13 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$1K |
| D1354 |
|
286 |
116 |
$632.50 |