| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
290 |
97 |
$34K |
| D1120 |
Prophylaxis - child |
712 |
694 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
310 |
94 |
$20K |
| D1206 |
Topical application of fluoride varnish |
823 |
802 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
707 |
690 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
69 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
58 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
552 |
254 |
$4K |
| D2934 |
|
35 |
12 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
102 |
$4K |
| D0272 |
Bitewings - two radiographic images |
189 |
188 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
32 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
314 |
$3K |
| D1110 |
Prophylaxis - adult |
73 |
72 |
$3K |
| D9248 |
|
68 |
59 |
$3K |
| D1510 |
|
17 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
67 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
19 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |