| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
195 |
84 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
249 |
99 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
198 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
29 |
$7K |
| D1120 |
Prophylaxis - child |
149 |
148 |
$6K |
| D9248 |
|
92 |
88 |
$6K |
| D9420 |
|
39 |
39 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
110 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
144 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
99 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$996.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$957.00 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$425.00 |