| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
403 |
194 |
$81K |
| D1120 |
Prophylaxis - child |
1,469 |
1,469 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
401 |
278 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,224 |
1,224 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,427 |
1,427 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
389 |
212 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
168 |
$21K |
| D0272 |
Bitewings - two radiographic images |
589 |
589 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
727 |
716 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$13K |
| D9310 |
|
156 |
156 |
$12K |
| D0240 |
|
514 |
286 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
807 |
340 |
$11K |
| D1351 |
Sealant - per tooth |
123 |
56 |
$4K |
| D1510 |
|
19 |
13 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$1K |