| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
355 |
73 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
339 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
70 |
$15K |
| D1120 |
Prophylaxis - child |
343 |
329 |
$9K |
| D1351 |
Sealant - per tooth |
361 |
89 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
176 |
152 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
645 |
248 |
$7K |
| D1206 |
Topical application of fluoride varnish |
369 |
359 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
274 |
$4K |
| D0272 |
Bitewings - two radiographic images |
224 |
209 |
$3K |
| D0330 |
Panoramic radiographic image |
64 |
62 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
50 |
$1K |