| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
989 |
182 |
$102K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,150 |
223 |
$74K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
438 |
120 |
$34K |
| D2390 |
|
100 |
24 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,422 |
348 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
68 |
$11K |
| D2332 |
|
134 |
67 |
$9K |
| D2335 |
|
62 |
31 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
170 |
170 |
$3K |
| D1510 |
|
18 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
324 |
$2K |
| D1120 |
Prophylaxis - child |
61 |
61 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
87 |
87 |
$2K |
| D2331 |
|
26 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$289.00 |