| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
615 |
192 |
$61K |
| D1120 |
Prophylaxis - child |
966 |
821 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
337 |
112 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
458 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
129 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
953 |
807 |
$14K |
| D0272 |
Bitewings - two radiographic images |
745 |
638 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
491 |
420 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
954 |
819 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
75 |
$9K |
| D9420 |
|
134 |
119 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
260 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
911 |
777 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
45 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
260 |
209 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
71 |
$4K |
| D2932 |
|
34 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
153 |
48 |
$3K |
| D0274 |
Bitewings - four radiographic images |
19 |
13 |
$378.48 |