| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
33 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
33 |
$4K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
30 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
98 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
31 |
$3K |
| D1206 |
Topical application of fluoride varnish |
145 |
145 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
141 |
$3K |
| D9248 |
|
33 |
33 |
$3K |
| D1351 |
Sealant - per tooth |
69 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
53 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$1K |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$821.34 |
| D0140 |
Limited oral evaluation - problem focused |
43 |
42 |
$774.48 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
44 |
$551.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
14 |
$138.21 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$130.97 |