| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
433 |
151 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
434 |
430 |
$28K |
| D1120 |
Prophylaxis - child |
573 |
572 |
$27K |
| D1206 |
Topical application of fluoride varnish |
575 |
574 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
96 |
$17K |
| D0240 |
|
585 |
298 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
922 |
399 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
137 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
454 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
26 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$4K |
| D0272 |
Bitewings - two radiographic images |
152 |
150 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
88 |
$4K |
| D1351 |
Sealant - per tooth |
85 |
27 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
16 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$549.20 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
49 |
$0.00 |