| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
533 |
165 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
386 |
138 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
246 |
111 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
154 |
70 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
279 |
$8K |
| D0240 |
|
286 |
144 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
49 |
$5K |
| D1120 |
Prophylaxis - child |
144 |
144 |
$4K |
| D1351 |
Sealant - per tooth |
122 |
43 |
$3K |
| D1206 |
Topical application of fluoride varnish |
199 |
199 |
$3K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
30 |
$427.08 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$276.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
15 |
$126.90 |