| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,013 |
586 |
$232K |
| D1120 |
Prophylaxis - child |
6,739 |
6,694 |
$194K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,029 |
581 |
$144K |
| D1206 |
Topical application of fluoride varnish |
7,305 |
7,255 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
5,833 |
5,795 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,196 |
620 |
$87K |
| D0272 |
Bitewings - two radiographic images |
2,865 |
2,840 |
$52K |
| D9999 |
Unspecified adjunctive procedure, by report |
322 |
320 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
540 |
267 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,319 |
1,306 |
$35K |
| D1351 |
Sealant - per tooth |
947 |
271 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
882 |
865 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
645 |
609 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
458 |
436 |
$16K |
| D0330 |
Panoramic radiographic image |
283 |
281 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
65 |
$12K |
| D0240 |
|
535 |
286 |
$6K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |