| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
189 |
67 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
796 |
790 |
$22K |
| D1120 |
Prophylaxis - child |
537 |
531 |
$19K |
| D1110 |
Prophylaxis - adult |
270 |
270 |
$14K |
| D0272 |
Bitewings - two radiographic images |
525 |
519 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
840 |
834 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
945 |
935 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
902 |
895 |
$10K |
| D0274 |
Bitewings - four radiographic images |
268 |
268 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
45 |
$6K |
| D1351 |
Sealant - per tooth |
134 |
27 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
16 |
$3K |
| D9248 |
|
18 |
17 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
34 |
$921.74 |
| D0603 |
|
753 |
747 |
$0.00 |
| D0602 |
|
183 |
182 |
$0.00 |