| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
227 |
55 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
91 |
$21K |
| D1120 |
Prophylaxis - child |
461 |
459 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
153 |
62 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
473 |
471 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
326 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$6K |
| D0240 |
|
228 |
120 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
319 |
127 |
$4K |
| D1351 |
Sealant - per tooth |
128 |
52 |
$4K |
| D9420 |
|
26 |
26 |
$4K |
| D9310 |
|
49 |
49 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
145 |
$3K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
31 |
$1K |