| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
779 |
224 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
471 |
262 |
$4K |
| D9248 |
|
475 |
427 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
234 |
133 |
$2K |
| D1120 |
Prophylaxis - child |
579 |
539 |
$2K |
| D0272 |
Bitewings - two radiographic images |
632 |
585 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
710 |
658 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
160 |
114 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
492 |
456 |
$1K |
| D1110 |
Prophylaxis - adult |
126 |
115 |
$969.33 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
134 |
$958.50 |
| D1206 |
Topical application of fluoride varnish |
289 |
270 |
$689.75 |
| D1351 |
Sealant - per tooth |
156 |
90 |
$675.05 |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
293 |
$622.75 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
66 |
36 |
$525.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
215 |
$360.00 |
| D9920 |
|
27 |
25 |
$233.75 |
| D2335 |
|
66 |
27 |
$154.74 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
27 |
$111.00 |
| D3230 |
|
38 |
12 |
$0.00 |