| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
106 |
49 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
135 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
28 |
$6K |
| D1120 |
Prophylaxis - child |
136 |
131 |
$5K |
| D1351 |
Sealant - per tooth |
119 |
39 |
$5K |
| D1206 |
Topical application of fluoride varnish |
124 |
121 |
$4K |
| D0330 |
Panoramic radiographic image |
39 |
34 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
50 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
81 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
123 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
68 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
20 |
17 |
$671.20 |