| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
132 |
37 |
$18K |
| D9248 |
|
27 |
27 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
17 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
92 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
107 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
110 |
$1K |
| D0160 |
|
77 |
74 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
30 |
$426.30 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
13 |
$375.05 |
| D1330 |
|
20 |
20 |
$220.50 |
| D0603 |
|
108 |
106 |
$0.00 |