| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
555 |
231 |
$73K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,011 |
457 |
$61K |
| D1120 |
Prophylaxis - child |
1,708 |
1,707 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,099 |
2,094 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,638 |
1,636 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
662 |
624 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
456 |
303 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
255 |
$20K |
| D1351 |
Sealant - per tooth |
663 |
244 |
$16K |
| D0272 |
Bitewings - two radiographic images |
807 |
805 |
$13K |
| D1110 |
Prophylaxis - adult |
350 |
348 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
479 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
525 |
516 |
$8K |
| D1354 |
|
761 |
277 |
$5K |
| D0330 |
Panoramic radiographic image |
122 |
122 |
$5K |
| D1330 |
|
409 |
408 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
229 |
$2K |
| D0240 |
|
66 |
62 |
$804.00 |
| D0603 |
|
69 |
69 |
$656.00 |