| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
399 |
101 |
$45K |
| D1120 |
Prophylaxis - child |
1,043 |
1,043 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
918 |
918 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,005 |
1,002 |
$20K |
| D1351 |
Sealant - per tooth |
459 |
124 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
105 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
148 |
63 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
101 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
260 |
233 |
$7K |
| D0272 |
Bitewings - two radiographic images |
473 |
471 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
152 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
408 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
557 |
275 |
$2K |
| D9420 |
|
28 |
28 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$594.00 |
| D0240 |
|
73 |
51 |
$490.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$324.00 |