| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,749 |
371 |
$168K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,048 |
328 |
$66K |
| D2390 |
|
213 |
73 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
141 |
$14K |
| D1120 |
Prophylaxis - child |
340 |
340 |
$10K |
| D2330 |
|
162 |
96 |
$8K |
| D1206 |
Topical application of fluoride varnish |
426 |
426 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
511 |
169 |
$6K |
| D1510 |
|
46 |
30 |
$6K |
| D1351 |
Sealant - per tooth |
154 |
54 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
24 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
91 |
91 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
201 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$723.40 |