| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
177 |
44 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
46 |
$14K |
| D1120 |
Prophylaxis - child |
187 |
186 |
$13K |
| D1206 |
Topical application of fluoride varnish |
226 |
224 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$7K |
| D0350 |
|
120 |
112 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$3K |
| D0240 |
|
81 |
79 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
61 |
$2K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$2K |
| D9420 |
|
14 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
118 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
42 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
45 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
64 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$679.34 |
| D0190 |
|
15 |
14 |
$268.20 |