| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
919 |
146 |
$109K |
| D1120 |
Prophylaxis - child |
1,337 |
1,320 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
594 |
135 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,982 |
1,944 |
$32K |
| D0330 |
Panoramic radiographic image |
542 |
537 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,164 |
1,153 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
777 |
767 |
$22K |
| D1110 |
Prophylaxis - adult |
556 |
552 |
$20K |
| D0274 |
Bitewings - four radiographic images |
558 |
551 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
55 |
$15K |
| D0272 |
Bitewings - two radiographic images |
603 |
595 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
25 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
232 |
225 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
127 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
169 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$772.52 |
| D9248 |
|
12 |
12 |
$0.00 |