| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
834 |
479 |
$142K |
| D1352 |
|
1,802 |
581 |
$127K |
| D1351 |
Sealant - per tooth |
3,479 |
633 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
573 |
$102K |
| D1354 |
|
4,248 |
1,141 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,154 |
570 |
$99K |
| D1120 |
Prophylaxis - child |
1,951 |
1,950 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,582 |
1,582 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,347 |
1,347 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,978 |
1,957 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,406 |
1,548 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
212 |
170 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
636 |
630 |
$28K |
| D1110 |
Prophylaxis - adult |
431 |
431 |
$21K |
| D1510 |
|
101 |
70 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
152 |
110 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
685 |
685 |
$15K |
| D0272 |
Bitewings - two radiographic images |
597 |
597 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$3K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$730.97 |
| D0603 |
|
320 |
319 |
$0.00 |