| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
345 |
73 |
$39K |
| D1120 |
Prophylaxis - child |
347 |
338 |
$11K |
| D1206 |
Topical application of fluoride varnish |
489 |
475 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
352 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
26 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
317 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
38 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
289 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
107 |
$2K |
| D8670 |
Periodic orthodontic treatment visit |
14 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$570.44 |
| D9420 |
|
134 |
126 |
$55.00 |