| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
79 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
46 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
178 |
160 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
34 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
27 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
42 |
$1K |
| D1351 |
Sealant - per tooth |
21 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
77 |
$1K |
| D1206 |
Topical application of fluoride varnish |
50 |
41 |
$742.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
17 |
$491.55 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$281.40 |