| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,069 |
284 |
$215K |
| D1120 |
Prophylaxis - child |
1,868 |
1,718 |
$40K |
| D2934 |
|
145 |
40 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
275 |
100 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
558 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,020 |
939 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,255 |
1,165 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
567 |
517 |
$14K |
| D1206 |
Topical application of fluoride varnish |
503 |
437 |
$10K |
| D9310 |
|
122 |
121 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
29 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
367 |
335 |
$4K |
| D2330 |
|
45 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$529.49 |