| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,075 |
296 |
$104K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
729 |
255 |
$45K |
| D1120 |
Prophylaxis - child |
1,738 |
1,679 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
375 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,091 |
2,001 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,753 |
1,674 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
260 |
136 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
158 |
$12K |
| D1110 |
Prophylaxis - adult |
401 |
367 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
362 |
$10K |
| D0272 |
Bitewings - two radiographic images |
755 |
739 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
649 |
$3K |
| D0274 |
Bitewings - four radiographic images |
244 |
229 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
242 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
24 |
$924.16 |
| D1351 |
Sealant - per tooth |
38 |
12 |
$785.40 |
| D0240 |
|
24 |
13 |
$214.20 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$213.39 |