| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
268 |
96 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
123 |
25 |
$31K |
| D1120 |
Prophylaxis - child |
468 |
451 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
545 |
$28K |
| D1206 |
Topical application of fluoride varnish |
678 |
652 |
$28K |
| D1110 |
Prophylaxis - adult |
262 |
252 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
85 |
$22K |
| D0272 |
Bitewings - two radiographic images |
395 |
382 |
$17K |
| D0274 |
Bitewings - four radiographic images |
254 |
248 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
92 |
$8K |
| D1351 |
Sealant - per tooth |
136 |
46 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
92 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
156 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$4K |
| D9420 |
|
12 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
29 |
$3K |
| D2140 |
|
18 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$895.00 |