| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
562 |
164 |
$95K |
| D1206 |
Topical application of fluoride varnish |
1,967 |
1,935 |
$62K |
| D1120 |
Prophylaxis - child |
1,465 |
1,446 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,292 |
1,271 |
$42K |
| D1351 |
Sealant - per tooth |
737 |
208 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,037 |
1,024 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
143 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
405 |
362 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
102 |
$15K |
| D0240 |
|
1,465 |
610 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
281 |
281 |
$9K |
| D1110 |
Prophylaxis - adult |
199 |
194 |
$9K |
| D0274 |
Bitewings - four radiographic images |
268 |
265 |
$7K |
| D1354 |
|
241 |
100 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
284 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
16 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
132 |
$1K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$396.90 |