| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,186 |
221 |
$197K |
| D1206 |
Topical application of fluoride varnish |
2,684 |
2,347 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,163 |
1,900 |
$69K |
| D1120 |
Prophylaxis - child |
2,494 |
2,148 |
$57K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,137 |
1,010 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
505 |
$27K |
| D1351 |
Sealant - per tooth |
1,053 |
222 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
127 |
40 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,278 |
1,091 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,107 |
951 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
410 |
310 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
73 |
$8K |
| D0330 |
Panoramic radiographic image |
168 |
153 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
174 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,143 |
958 |
$2K |
| D0274 |
Bitewings - four radiographic images |
22 |
22 |
$315.63 |