| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
227 |
38 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
881 |
$25K |
| D1120 |
Prophylaxis - child |
584 |
574 |
$20K |
| D1110 |
Prophylaxis - adult |
366 |
364 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
937 |
925 |
$13K |
| D0274 |
Bitewings - four radiographic images |
395 |
392 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
66 |
$12K |
| D0272 |
Bitewings - two radiographic images |
489 |
484 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$6K |
| D1351 |
Sealant - per tooth |
173 |
55 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
352 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
26 |
$4K |
| D0350 |
|
151 |
144 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
218 |
181 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
65 |
$2K |
| D9420 |
|
68 |
65 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$996.57 |
| D0603 |
|
1,133 |
1,125 |
$0.00 |