| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
476 |
89 |
$37K |
| D1120 |
Prophylaxis - child |
333 |
333 |
$15K |
| D1206 |
Topical application of fluoride varnish |
568 |
567 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
304 |
$8K |
| D0272 |
Bitewings - two radiographic images |
289 |
289 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
61 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
95 |
$4K |
| D9420 |
|
47 |
47 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$941.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
51 |
$481.74 |