| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
144 |
98 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,352 |
1,231 |
$27K |
| D1120 |
Prophylaxis - child |
815 |
808 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
150 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
743 |
742 |
$17K |
| D1351 |
Sealant - per tooth |
531 |
89 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
276 |
230 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
179 |
78 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
320 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
126 |
$6K |
| D0240 |
|
251 |
220 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
196 |
194 |
$4K |
| D0272 |
Bitewings - two radiographic images |
217 |
216 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
24 |
$4K |
| D1330 |
|
544 |
543 |
$3K |
| D0603 |
|
339 |
339 |
$3K |
| D1310 |
|
530 |
530 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
36 |
$3K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$3K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$3K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
116 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
53 |
$808.68 |