| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
479 |
108 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,209 |
1,013 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
443 |
203 |
$40K |
| D1120 |
Prophylaxis - child |
1,455 |
1,250 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,448 |
1,242 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,757 |
782 |
$18K |
| D2390 |
|
99 |
27 |
$18K |
| D1351 |
Sealant - per tooth |
607 |
177 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
447 |
351 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,078 |
920 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
235 |
97 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
59 |
$10K |
| D9420 |
|
82 |
82 |
$10K |
| D0272 |
Bitewings - two radiographic images |
630 |
542 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
351 |
$9K |
| D0330 |
Panoramic radiographic image |
145 |
126 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
83 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$2K |
| D0240 |
|
44 |
22 |
$735.24 |