| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
280 |
53 |
$48K |
| D1120 |
Prophylaxis - child |
558 |
510 |
$29K |
| D1351 |
Sealant - per tooth |
464 |
94 |
$17K |
| D1206 |
Topical application of fluoride varnish |
689 |
631 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
329 |
309 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
195 |
$12K |
| D0272 |
Bitewings - two radiographic images |
348 |
315 |
$11K |
| D0240 |
|
279 |
134 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
85 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
173 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
40 |
37 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$716.65 |