| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
770 |
198 |
$82K |
| D1120 |
Prophylaxis - child |
838 |
814 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
743 |
716 |
$21K |
| D1206 |
Topical application of fluoride varnish |
899 |
874 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
139 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
145 |
$15K |
| D1351 |
Sealant - per tooth |
451 |
161 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
153 |
40 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
84 |
$11K |
| D9248 |
|
157 |
136 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
214 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
232 |
206 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
209 |
$5K |
| D0272 |
Bitewings - two radiographic images |
226 |
218 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
124 |
$3K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
62 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
110 |
$1K |