| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,586 |
322 |
$153K |
| D7140 |
Extraction, erupted tooth or exposed root |
683 |
230 |
$44K |
| D2390 |
|
218 |
71 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
324 |
147 |
$15K |
| D1120 |
Prophylaxis - child |
300 |
300 |
$8K |
| D2330 |
|
142 |
78 |
$7K |
| D1206 |
Topical application of fluoride varnish |
386 |
386 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
92 |
55 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
451 |
139 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
43 |
$4K |
| D1351 |
Sealant - per tooth |
140 |
44 |
$4K |
| D1510 |
|
15 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
141 |
$1K |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$752.00 |
| D0120 |
Periodic oral evaluation - established patient |
33 |
33 |
$669.00 |
| D1330 |
|
234 |
224 |
$0.00 |
| D9994 |
|
175 |
175 |
$0.00 |
| D1310 |
|
233 |
223 |
$0.00 |
| D9991 |
|
46 |
46 |
$0.00 |