| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
274 |
69 |
$55K |
| D1120 |
Prophylaxis - child |
257 |
257 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
45 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
31 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
55 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
217 |
217 |
$6K |
| D1206 |
Topical application of fluoride varnish |
213 |
213 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
28 |
$4K |
| D9420 |
|
27 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$2K |
| D0240 |
|
48 |
32 |
$1K |
| D1351 |
Sealant - per tooth |
38 |
14 |
$972.88 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$816.21 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$710.11 |