| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
514 |
127 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
411 |
144 |
$23K |
| D1120 |
Prophylaxis - child |
505 |
488 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
467 |
450 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
318 |
305 |
$5K |
| D0240 |
|
200 |
157 |
$3K |
| D0272 |
Bitewings - two radiographic images |
279 |
267 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
81 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
85 |
$420.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
30 |
$170.00 |
| D1999 |
|
15 |
14 |
$0.00 |