| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
122 |
46 |
$14K |
| D1120 |
Prophylaxis - child |
235 |
235 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
33 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
223 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
214 |
$4K |
| D0272 |
Bitewings - two radiographic images |
139 |
139 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
23 |
$3K |
| D9420 |
|
38 |
38 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
69 |
67 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$820.96 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
66 |
$731.64 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$527.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$470.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$270.32 |