| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
254 |
60 |
$6K |
| D1120 |
Prophylaxis - child |
1,690 |
1,662 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
310 |
117 |
$3K |
| D1206 |
Topical application of fluoride varnish |
1,906 |
1,867 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
1,684 |
1,655 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
137 |
$911.92 |
| D0272 |
Bitewings - two radiographic images |
808 |
782 |
$798.94 |
| D1351 |
Sealant - per tooth |
1,094 |
340 |
$714.14 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
42 |
$364.41 |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
537 |
$340.48 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
431 |
391 |
$321.75 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
71 |
$283.12 |
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
34 |
$149.80 |
| D1354 |
|
541 |
196 |
$142.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
261 |
200 |
$128.40 |
| D0330 |
Panoramic radiographic image |
52 |
48 |
$95.00 |
| D0140 |
Limited oral evaluation - problem focused |
67 |
56 |
$68.88 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$59.98 |
| D1110 |
Prophylaxis - adult |
118 |
115 |
$47.56 |
| D1330 |
|
1,801 |
1,667 |
$0.00 |
| D0603 |
|
1,186 |
1,007 |
$0.00 |