| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
382 |
101 |
$44K |
| D1120 |
Prophylaxis - child |
600 |
591 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
321 |
99 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
344 |
$11K |
| D1206 |
Topical application of fluoride varnish |
597 |
588 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
296 |
293 |
$7K |
| D0272 |
Bitewings - two radiographic images |
300 |
296 |
$6K |
| D0330 |
Panoramic radiographic image |
89 |
89 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
28 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
86 |
79 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
101 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
15 |
$897.18 |
| D9420 |
|
95 |
92 |
$608.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
14 |
$167.70 |