| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,450 |
528 |
$290K |
| D9420 |
|
984 |
640 |
$81K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
773 |
254 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
978 |
976 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,283 |
616 |
$14K |
| D1120 |
Prophylaxis - child |
618 |
617 |
$14K |
| D2330 |
|
104 |
37 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
41 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
606 |
604 |
$8K |
| D0272 |
Bitewings - two radiographic images |
616 |
615 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
26 |
$4K |
| D1310 |
|
47 |
47 |
$930.00 |
| D0603 |
|
47 |
47 |
$465.00 |