| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
366 |
77 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
233 |
66 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$1K |
| D2330 |
|
32 |
16 |
$923.00 |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$910.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$640.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
18 |
$624.00 |
| D9310 |
|
54 |
54 |
$306.00 |
| D0603 |
|
102 |
102 |
$73.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$60.00 |