| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
555 |
147 |
$67K |
| D1120 |
Prophylaxis - child |
2,332 |
1,922 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,407 |
1,349 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,506 |
1,500 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
103 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
259 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
520 |
373 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
58 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
604 |
304 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
559 |
130 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
382 |
334 |
$4K |
| D0330 |
Panoramic radiographic image |
63 |
61 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
133 |
89 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
25 |
$1K |