| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,556 |
1,807 |
$1.05M |
| 69436 |
Tympanostomy (requiring insertion of ventilating tube), general anesthesia |
3,034 |
1,525 |
$595K |
| 42820 |
Tonsillectomy and adenoidectomy; younger than age 12 |
721 |
721 |
$325K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
768 |
689 |
$204K |
| D7140 |
Extraction, erupted tooth or exposed root |
577 |
528 |
$160K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
257 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
235 |
$63K |
| D2929 |
|
201 |
186 |
$51K |
| D2330 |
|
198 |
192 |
$50K |
| 42830 |
|
65 |
65 |
$28K |
| D1120 |
Prophylaxis - child |
272 |
269 |
$25K |
| D7240 |
Removal of impacted tooth - completely bony |
92 |
53 |
$23K |
| D1206 |
Topical application of fluoride varnish |
194 |
194 |
$22K |
| D2332 |
|
28 |
28 |
$7K |
| D2331 |
|
24 |
24 |
$5K |
| D1351 |
Sealant - per tooth |
13 |
12 |
$4K |