| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,162 |
723 |
$229K |
| D1120 |
Prophylaxis - child |
5,290 |
5,280 |
$226K |
| D0120 |
Periodic oral evaluation - established patient |
5,649 |
5,639 |
$196K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,993 |
5,983 |
$170K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
887 |
636 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,182 |
684 |
$104K |
| D1110 |
Prophylaxis - adult |
1,105 |
1,103 |
$61K |
| D1351 |
Sealant - per tooth |
1,711 |
543 |
$55K |
| D3240 |
|
329 |
181 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
460 |
334 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
608 |
604 |
$37K |
| D0330 |
Panoramic radiographic image |
194 |
193 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
72 |
47 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
369 |
362 |
$7K |
| D2335 |
|
22 |
13 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
25 |
$714.00 |