| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
800 |
245 |
$158K |
| D1120 |
Prophylaxis - child |
1,089 |
1,089 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,189 |
1,189 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
170 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
341 |
155 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
705 |
705 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
164 |
$24K |
| D0272 |
Bitewings - two radiographic images |
447 |
447 |
$11K |
| D0240 |
|
412 |
239 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
457 |
453 |
$9K |
| D9420 |
|
54 |
54 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
422 |
201 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$5K |
| D9310 |
|
24 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
27 |
13 |
$853.94 |
| D1354 |
|
24 |
12 |
$612.88 |