| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
602 |
150 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
185 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
162 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
483 |
482 |
$10K |
| D1120 |
Prophylaxis - child |
426 |
426 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
294 |
284 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
540 |
540 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
86 |
31 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
61 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$4K |
| D0272 |
Bitewings - two radiographic images |
302 |
302 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
347 |
200 |
$3K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$3K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
284 |
$2K |
| D1351 |
Sealant - per tooth |
40 |
16 |
$796.00 |
| D1206 |
Topical application of fluoride varnish |
60 |
59 |
$750.00 |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$501.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$288.00 |