| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
179 |
43 |
$27K |
| D1120 |
Prophylaxis - child |
236 |
236 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
36 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$9K |
| D1206 |
Topical application of fluoride varnish |
285 |
285 |
$8K |
| D0350 |
|
181 |
177 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
16 |
$5K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
265 |
260 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
140 |
139 |
$3K |
| D9420 |
|
25 |
25 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
69 |
62 |
$2K |
| D0240 |
|
53 |
53 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$498.55 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$410.43 |