| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
468 |
139 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
621 |
240 |
$42K |
| D1120 |
Prophylaxis - child |
1,284 |
1,249 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,529 |
1,485 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
939 |
931 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
518 |
503 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
362 |
349 |
$11K |
| D0272 |
Bitewings - two radiographic images |
827 |
799 |
$10K |
| D1351 |
Sealant - per tooth |
198 |
61 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
65 |
$6K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D1354 |
|
99 |
46 |
$2K |
| D0240 |
|
138 |
112 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
128 |
$864.75 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$240.00 |