| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,705 |
303 |
$347K |
| D9420 |
|
292 |
288 |
$53K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
262 |
85 |
$34K |
| D2390 |
|
159 |
42 |
$33K |
| D1120 |
Prophylaxis - child |
211 |
211 |
$10K |
| D1206 |
Topical application of fluoride varnish |
209 |
209 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
128 |
128 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
46 |
$1K |
| D1351 |
Sealant - per tooth |
32 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$861.08 |