| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
414 |
99 |
$52K |
| D1120 |
Prophylaxis - child |
766 |
753 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
636 |
628 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
813 |
800 |
$16K |
| D0272 |
Bitewings - two radiographic images |
520 |
516 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
689 |
320 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
68 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
38 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$6K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$6K |
| D9920 |
|
108 |
87 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
349 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
106 |
106 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
73 |
$3K |
| D9420 |
|
12 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$864.18 |