| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
564 |
130 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
75 |
$17K |
| D1120 |
Prophylaxis - child |
475 |
475 |
$14K |
| D1206 |
Topical application of fluoride varnish |
458 |
458 |
$8K |
| D9310 |
|
172 |
172 |
$8K |
| D1351 |
Sealant - per tooth |
339 |
116 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
265 |
$8K |
| D2934 |
|
42 |
13 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
75 |
46 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
51 |
$7K |
| D0272 |
Bitewings - two radiographic images |
311 |
311 |
$6K |
| D9248 |
|
41 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
341 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
53 |
$5K |
| D0330 |
Panoramic radiographic image |
94 |
94 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
97 |
97 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
302 |
258 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
73 |
68 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$1K |
| D0350 |
|
36 |
36 |
$1K |