| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
552 |
552 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
106 |
44 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
45 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
81 |
36 |
$9K |
| D1206 |
Topical application of fluoride varnish |
325 |
325 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
28 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
209 |
209 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
558 |
149 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
197 |
197 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
83 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
203 |
$3K |
| D9248 |
|
42 |
41 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
14 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
49 |
49 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$700.00 |