| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
493 |
135 |
$54K |
| D1120 |
Prophylaxis - child |
1,219 |
1,014 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,552 |
1,284 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,179 |
974 |
$18K |
| D0272 |
Bitewings - two radiographic images |
556 |
463 |
$10K |
| D1110 |
Prophylaxis - adult |
222 |
185 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
250 |
218 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
265 |
212 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
54 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
632 |
507 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
504 |
422 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
18 |
$3K |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$562.72 |