| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
484 |
148 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
210 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,561 |
1,561 |
$29K |
| D1120 |
Prophylaxis - child |
989 |
989 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,164 |
1,164 |
$27K |
| D9248 |
|
182 |
182 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
275 |
136 |
$18K |
| D1110 |
Prophylaxis - adult |
250 |
250 |
$9K |
| D0272 |
Bitewings - two radiographic images |
531 |
531 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
111 |
$8K |
| D9920 |
|
138 |
138 |
$8K |
| D1351 |
Sealant - per tooth |
292 |
57 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
156 |
152 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
36 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
87 |
$4K |
| D0330 |
Panoramic radiographic image |
79 |
79 |
$3K |
| D1330 |
|
406 |
406 |
$2K |
| D0603 |
|
195 |
195 |
$2K |
| D0602 |
|
108 |
108 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$479.00 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
55 |
$446.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$336.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$262.08 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$115.60 |