| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
361 |
68 |
$29K |
| D1120 |
Prophylaxis - child |
858 |
858 |
$28K |
| D1206 |
Topical application of fluoride varnish |
994 |
994 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
739 |
739 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
164 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
197 |
59 |
$12K |
| D1351 |
Sealant - per tooth |
335 |
108 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
931 |
928 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
213 |
77 |
$8K |
| D1110 |
Prophylaxis - adult |
170 |
170 |
$7K |
| D0272 |
Bitewings - two radiographic images |
489 |
489 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
877 |
877 |
$6K |
| D0274 |
Bitewings - four radiographic images |
263 |
263 |
$5K |
| D2335 |
|
46 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
44 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$636.60 |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$456.64 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$150.99 |