| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
327 |
126 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
340 |
188 |
$44K |
| D1120 |
Prophylaxis - child |
818 |
818 |
$36K |
| D1206 |
Topical application of fluoride varnish |
845 |
845 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
692 |
692 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
254 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
74 |
41 |
$10K |
| D0272 |
Bitewings - two radiographic images |
322 |
322 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
636 |
296 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
423 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
53 |
$8K |
| D1351 |
Sealant - per tooth |
63 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$432.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
21 |
$0.00 |