| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
214 |
59 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
372 |
366 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
47 |
$6K |
| D0240 |
|
398 |
158 |
$4K |
| D1120 |
Prophylaxis - child |
174 |
173 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
191 |
$3K |
| D0272 |
Bitewings - two radiographic images |
183 |
183 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
117 |
$1K |
| D1351 |
Sealant - per tooth |
80 |
26 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$972.99 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
52 |
$255.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
27 |
$50.00 |