| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
705 |
269 |
$69K |
| D1120 |
Prophylaxis - child |
2,670 |
2,574 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,019 |
2,910 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
2,508 |
2,417 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
545 |
325 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
441 |
210 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
422 |
267 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
569 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,078 |
1,038 |
$10K |
| D1351 |
Sealant - per tooth |
380 |
143 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
109 |
71 |
$7K |
| D1110 |
Prophylaxis - adult |
192 |
179 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
913 |
879 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
619 |
354 |
$3K |
| D2330 |
|
30 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
51 |
$776.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$544.20 |