| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
426 |
166 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
171 |
$41K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
148 |
66 |
$16K |
| D1120 |
Prophylaxis - child |
359 |
355 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
88 |
$13K |
| D9310 |
|
144 |
140 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
278 |
$12K |
| D1206 |
Topical application of fluoride varnish |
403 |
397 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
61 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
137 |
$8K |
| D0272 |
Bitewings - two radiographic images |
264 |
262 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
214 |
211 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
175 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
106 |
$2K |
| D0274 |
Bitewings - four radiographic images |
34 |
33 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$799.50 |