| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
388 |
129 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
332 |
177 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
241 |
103 |
$31K |
| D9420 |
|
132 |
132 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
94 |
$15K |
| D2330 |
|
171 |
94 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
167 |
88 |
$13K |
| D2331 |
|
111 |
56 |
$12K |
| D1120 |
Prophylaxis - child |
432 |
431 |
$8K |
| D1206 |
Topical application of fluoride varnish |
466 |
465 |
$6K |
| D0240 |
|
232 |
121 |
$5K |
| D0272 |
Bitewings - two radiographic images |
384 |
381 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
333 |
113 |
$4K |
| D2140 |
|
60 |
51 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
351 |
351 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
123 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$2K |