| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
482 |
140 |
$50K |
| D1120 |
Prophylaxis - child |
1,410 |
1,370 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,484 |
1,436 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
307 |
133 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,081 |
1,060 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
621 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
145 |
$12K |
| D1351 |
Sealant - per tooth |
444 |
127 |
$9K |
| D0272 |
Bitewings - two radiographic images |
697 |
676 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
132 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
472 |
449 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$2K |
| D1354 |
|
109 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
129 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$273.24 |
| D9420 |
|
26 |
14 |
$0.01 |
| D0601 |
|
138 |
138 |
$0.00 |
| D0603 |
|
202 |
199 |
$0.00 |
| D1330 |
|
402 |
398 |
$0.00 |
| D9986 |
|
15 |
14 |
$0.00 |
| D9987 |
|
52 |
51 |
$0.00 |