| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
722 |
135 |
$96K |
| D1120 |
Prophylaxis - child |
1,611 |
1,495 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
964 |
951 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,141 |
1,120 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
336 |
321 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
434 |
298 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
868 |
199 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
46 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
43 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
303 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
386 |
209 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
38 |
15 |
$3K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |