| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
722 |
197 |
$95K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
995 |
230 |
$83K |
| D9420 |
|
641 |
332 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
298 |
96 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
428 |
419 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
64 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
65 |
$10K |
| D1120 |
Prophylaxis - child |
283 |
274 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,269 |
280 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
516 |
$6K |
| D1206 |
Topical application of fluoride varnish |
269 |
262 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
142 |
137 |
$3K |
| D0272 |
Bitewings - two radiographic images |
437 |
419 |
$3K |
| D1999 |
|
378 |
361 |
$0.00 |
| D0190 |
|
168 |
163 |
$0.00 |