| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
309 |
94 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
147 |
$41K |
| D1120 |
Prophylaxis - child |
685 |
683 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
431 |
429 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
79 |
50 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
496 |
494 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
42 |
$8K |
| D9420 |
|
45 |
45 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
410 |
164 |
$5K |
| D0240 |
|
239 |
124 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
33 |
$4K |
| D1351 |
Sealant - per tooth |
130 |
53 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
200 |
$4K |
| D9310 |
|
43 |
43 |
$3K |
| D1206 |
Topical application of fluoride varnish |
313 |
313 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
47 |
46 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$516.00 |