| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
287 |
81 |
$30K |
| D1120 |
Prophylaxis - child |
1,093 |
1,088 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,380 |
1,374 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,111 |
1,109 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
196 |
91 |
$11K |
| D0272 |
Bitewings - two radiographic images |
688 |
685 |
$7K |
| D1110 |
Prophylaxis - adult |
197 |
196 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
185 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
42 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
49 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
121 |
$3K |
| D1351 |
Sealant - per tooth |
142 |
47 |
$3K |
| D0240 |
|
108 |
73 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
13 |
$1K |
| D1354 |
|
53 |
28 |
$750.00 |
| D2140 |
|
18 |
12 |
$720.00 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
70 |
$382.40 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$298.90 |