| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
657 |
196 |
$136K |
| D1120 |
Prophylaxis - child |
1,054 |
1,051 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,168 |
717 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
749 |
745 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,111 |
1,110 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
315 |
161 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
374 |
374 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
811 |
798 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
73 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
108 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
63 |
63 |
$3K |
| D1351 |
Sealant - per tooth |
27 |
13 |
$874.50 |
| D9310 |
|
12 |
12 |
$711.00 |