| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
929 |
310 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
833 |
291 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
444 |
169 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
340 |
162 |
$20K |
| D2933 |
|
108 |
41 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
304 |
304 |
$15K |
| D1206 |
Topical application of fluoride varnish |
602 |
597 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
530 |
$11K |
| D1120 |
Prophylaxis - child |
430 |
429 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
106 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$146.50 |
| D1330 |
|
20 |
20 |
$100.00 |