| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
936 |
204 |
$118K |
| D1120 |
Prophylaxis - child |
8,250 |
4,138 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
4,281 |
2,834 |
$57K |
| D1206 |
Topical application of fluoride varnish |
7,767 |
3,868 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
244 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
990 |
666 |
$18K |
| D0330 |
Panoramic radiographic image |
1,032 |
595 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,546 |
1,160 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
114 |
$17K |
| D0272 |
Bitewings - two radiographic images |
2,276 |
1,215 |
$15K |
| D0274 |
Bitewings - four radiographic images |
616 |
547 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
52 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
134 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
698 |
346 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
78 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
411 |
101 |
$3K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$779.00 |