| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
570 |
246 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
283 |
$56K |
| D1120 |
Prophylaxis - child |
1,258 |
1,239 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,579 |
1,547 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
611 |
605 |
$18K |
| D1110 |
Prophylaxis - adult |
308 |
294 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
98 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
377 |
341 |
$14K |
| D0272 |
Bitewings - two radiographic images |
508 |
504 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
685 |
649 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
181 |
$8K |
| D0330 |
Panoramic radiographic image |
157 |
156 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
45 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
101 |
100 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
105 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$775.00 |