| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
3,060 |
525 |
$98K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
544 |
126 |
$54K |
| D1120 |
Prophylaxis - child |
1,559 |
1,540 |
$49K |
| D1351 |
Sealant - per tooth |
1,753 |
607 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,908 |
1,887 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,820 |
1,798 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
168 |
$22K |
| D1110 |
Prophylaxis - adult |
539 |
533 |
$21K |
| D1206 |
Topical application of fluoride varnish |
607 |
597 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
161 |
60 |
$11K |
| D1330 |
|
575 |
573 |
$8K |
| D1310 |
|
574 |
572 |
$7K |
| D0274 |
Bitewings - four radiographic images |
232 |
228 |
$7K |
| D0272 |
Bitewings - two radiographic images |
403 |
399 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
38 |
$4K |
| D1321 |
|
157 |
157 |
$4K |
| D0330 |
Panoramic radiographic image |
95 |
95 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
158 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
13 |
$2K |
| D9110 |
|
51 |
51 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
127 |
$967.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
16 |
$161.68 |
| D1999 |
|
19 |
18 |
$0.00 |