| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
327 |
150 |
$27K |
| D1120 |
Prophylaxis - child |
1,150 |
1,145 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
899 |
895 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,366 |
1,361 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
441 |
441 |
$16K |
| D0272 |
Bitewings - two radiographic images |
792 |
787 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
113 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
327 |
285 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
618 |
288 |
$6K |
| D0240 |
|
421 |
307 |
$5K |
| D1110 |
Prophylaxis - adult |
184 |
184 |
$5K |
| D0274 |
Bitewings - four radiographic images |
204 |
204 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
375 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
51 |
27 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
33 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
64 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
74 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
13 |
$610.34 |