| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,789 |
601 |
$410K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,426 |
562 |
$201K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,230 |
1,008 |
$187K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,262 |
2,045 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,267 |
557 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,111 |
2,102 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
2,057 |
2,048 |
$25K |
| D4341 |
|
494 |
123 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
99 |
13 |
$2K |
| D9420 |
|
39 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
61 |
60 |
$673.26 |
| D7111 |
|
57 |
24 |
$653.79 |
| D0603 |
|
1,925 |
1,917 |
$0.00 |