| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
662 |
320 |
$138K |
| D7140 |
Extraction, erupted tooth or exposed root |
511 |
289 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
204 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,677 |
722 |
$37K |
| D1120 |
Prophylaxis - child |
756 |
756 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
448 |
$28K |
| D1206 |
Topical application of fluoride varnish |
702 |
702 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
843 |
841 |
$17K |
| D9310 |
|
196 |
196 |
$16K |
| D1351 |
Sealant - per tooth |
475 |
135 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
108 |
78 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
234 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
55 |
$8K |
| D9248 |
|
12 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$596.10 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$543.50 |