| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
379 |
68 |
$14K |
| D1120 |
Prophylaxis - child |
226 |
204 |
$9K |
| D1206 |
Topical application of fluoride varnish |
215 |
198 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
74 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
256 |
192 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
50 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
53 |
$810.00 |
| D1351 |
Sealant - per tooth |
31 |
12 |
$707.10 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
21 |
$698.04 |
| D0603 |
|
123 |
111 |
$465.00 |
| D9420 |
|
27 |
12 |
$409.90 |
| D0120 |
Periodic oral evaluation - established patient |
47 |
43 |
$375.00 |
| D0274 |
Bitewings - four radiographic images |
23 |
13 |
$164.99 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
13 |
$112.00 |
| D1330 |
|
202 |
194 |
$0.00 |