| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
139 |
85 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
425 |
$12K |
| D2140 |
|
184 |
125 |
$12K |
| D1110 |
Prophylaxis - adult |
229 |
220 |
$11K |
| D0272 |
Bitewings - two radiographic images |
317 |
301 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
89 |
64 |
$7K |
| D1120 |
Prophylaxis - child |
201 |
187 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
388 |
359 |
$7K |
| D1206 |
Topical application of fluoride varnish |
284 |
283 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
351 |
329 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
146 |
140 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
142 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$845.00 |