| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,747 |
286 |
$181K |
| D1120 |
Prophylaxis - child |
2,903 |
2,636 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,344 |
2,112 |
$46K |
| D1206 |
Topical application of fluoride varnish |
2,541 |
2,294 |
$42K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
450 |
128 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,798 |
1,642 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
723 |
695 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,570 |
738 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
458 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
62 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,012 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
265 |
$3K |