| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
446 |
200 |
$84K |
| D1120 |
Prophylaxis - child |
866 |
866 |
$35K |
| D1206 |
Topical application of fluoride varnish |
976 |
976 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
655 |
655 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
133 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
94 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
314 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
126 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
129 |
49 |
$16K |
| D0240 |
|
529 |
307 |
$11K |
| D9310 |
|
147 |
147 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
166 |
$10K |
| D0272 |
Bitewings - two radiographic images |
368 |
368 |
$9K |
| D9248 |
|
89 |
89 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
100 |
100 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
173 |
169 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$3K |
| D1351 |
Sealant - per tooth |
92 |
40 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
60 |
$2K |
| D9420 |
|
12 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$453.36 |