| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
337 |
99 |
$35K |
| D1120 |
Prophylaxis - child |
918 |
910 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,114 |
1,102 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
99 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
714 |
713 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
300 |
295 |
$7K |
| D0272 |
Bitewings - two radiographic images |
581 |
579 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
226 |
$6K |
| D1351 |
Sealant - per tooth |
260 |
69 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
34 |
$3K |
| D0240 |
|
190 |
139 |
$2K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
24 |
$2K |
| D1354 |
|
80 |
37 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
141 |
$801.92 |
| D2140 |
|
17 |
13 |
$680.00 |