| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
373 |
69 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
360 |
186 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
201 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
525 |
458 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
427 |
343 |
$16K |
| D0240 |
|
1,136 |
512 |
$16K |
| D1120 |
Prophylaxis - child |
637 |
559 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,464 |
375 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
83 |
$14K |
| D1351 |
Sealant - per tooth |
585 |
135 |
$14K |
| D1206 |
Topical application of fluoride varnish |
758 |
667 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
206 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
560 |
457 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
125 |
$3K |
| D1110 |
Prophylaxis - adult |
70 |
68 |
$3K |
| D0170 |
|
99 |
91 |
$3K |
| D0272 |
Bitewings - two radiographic images |
114 |
105 |
$2K |
| D9420 |
|
29 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$805.35 |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$684.18 |