| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
436 |
147 |
$81K |
| D1120 |
Prophylaxis - child |
1,237 |
1,220 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
462 |
239 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
828 |
807 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
440 |
212 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,372 |
1,353 |
$37K |
| D1354 |
|
2,168 |
397 |
$32K |
| D1351 |
Sealant - per tooth |
497 |
154 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
392 |
365 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
859 |
809 |
$17K |
| D0272 |
Bitewings - two radiographic images |
446 |
436 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,039 |
618 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
363 |
359 |
$11K |
| D0180 |
|
118 |
117 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
43 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
30 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
42 |
17 |
$3K |
| D9110 |
|
45 |
45 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$900.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$732.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$598.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$310.00 |
| D1330 |
|
601 |
560 |
$0.00 |