| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
512 |
205 |
$12K |
| D1351 |
Sealant - per tooth |
2,477 |
406 |
$9K |
| D1120 |
Prophylaxis - child |
1,910 |
1,895 |
$9K |
| D1206 |
Topical application of fluoride varnish |
1,918 |
1,896 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
1,262 |
1,254 |
$6K |
| D0272 |
Bitewings - two radiographic images |
864 |
855 |
$3K |
| D0330 |
Panoramic radiographic image |
284 |
282 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
484 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
275 |
166 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
44 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
188 |
$827.64 |
| D2140 |
|
89 |
58 |
$748.15 |
| D0240 |
|
500 |
277 |
$720.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
397 |
375 |
$598.29 |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
244 |
$396.22 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
347 |
204 |
$294.44 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D2330 |
|
85 |
39 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$0.00 |
| D2331 |
|
15 |
13 |
$0.00 |