| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,055 |
181 |
$157K |
| D9420 |
|
260 |
259 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
323 |
115 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
390 |
123 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
225 |
$10K |
| D0240 |
|
584 |
297 |
$10K |
| D1120 |
Prophylaxis - child |
296 |
295 |
$8K |
| D1351 |
Sealant - per tooth |
375 |
138 |
$6K |
| D1206 |
Topical application of fluoride varnish |
307 |
306 |
$5K |
| D0272 |
Bitewings - two radiographic images |
281 |
280 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
26 |
13 |
$3K |
| 99199 |
Unlisted special service, procedure or report |
155 |
155 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
54 |
$842.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
24 |
$705.36 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$371.70 |
| D3120 |
|
123 |
62 |
$0.00 |
| D0191 |
|
14 |
14 |
$0.00 |