| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
528 |
130 |
$110K |
| D7140 |
Extraction, erupted tooth or exposed root |
479 |
145 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
74 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
58 |
$19K |
| D2929 |
|
39 |
15 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
151 |
$11K |
| D0240 |
|
292 |
167 |
$10K |
| D1120 |
Prophylaxis - child |
170 |
156 |
$9K |
| D0272 |
Bitewings - two radiographic images |
216 |
200 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
87 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
147 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
106 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
36 |
$1K |