| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,045 |
226 |
$178K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
180 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
277 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
276 |
275 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
24 |
$5K |
| D0272 |
Bitewings - two radiographic images |
284 |
282 |
$5K |
| D0240 |
|
230 |
228 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
279 |
$3K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$2K |
| D3120 |
|
22 |
12 |
$770.00 |
| D1330 |
|
13 |
13 |
$93.60 |