| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
613 |
142 |
$65K |
| D7140 |
Extraction, erupted tooth or exposed root |
732 |
272 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
1,062 |
$18K |
| D1120 |
Prophylaxis - child |
762 |
752 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
586 |
572 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
948 |
936 |
$13K |
| D0330 |
Panoramic radiographic image |
273 |
262 |
$12K |
| D1110 |
Prophylaxis - adult |
274 |
269 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
28 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
569 |
136 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
395 |
386 |
$2K |