| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
451 |
204 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
189 |
$37K |
| D1120 |
Prophylaxis - child |
793 |
792 |
$33K |
| D1206 |
Topical application of fluoride varnish |
802 |
800 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
338 |
334 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
594 |
594 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
92 |
$18K |
| D0272 |
Bitewings - two radiographic images |
344 |
344 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
665 |
347 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
433 |
$8K |
| D1351 |
Sealant - per tooth |
122 |
51 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
295 |
257 |
$0.00 |