| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,330 |
312 |
$452K |
| D7140 |
Extraction, erupted tooth or exposed root |
340 |
94 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
215 |
69 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
343 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
179 |
$14K |
| D9420 |
|
122 |
111 |
$10K |
| D1120 |
Prophylaxis - child |
99 |
98 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
350 |
$2K |
| D0272 |
Bitewings - two radiographic images |
113 |
110 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,382 |
317 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
73 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
42 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$180.00 |