| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
347 |
68 |
$65K |
| D1120 |
Prophylaxis - child |
1,008 |
998 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,020 |
1,010 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
130 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
993 |
983 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
324 |
$11K |
| D0240 |
|
772 |
304 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
285 |
263 |
$8K |
| D0272 |
Bitewings - two radiographic images |
612 |
601 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
74 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
89 |
$6K |
| D1351 |
Sealant - per tooth |
135 |
36 |
$6K |
| D1110 |
Prophylaxis - adult |
132 |
132 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
375 |
130 |
$3K |
| D1206 |
Topical application of fluoride varnish |
100 |
100 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
213 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$932.52 |