| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,159 |
263 |
$218K |
| D9410 |
|
151 |
151 |
$75K |
| D2934 |
|
326 |
112 |
$55K |
| D1120 |
Prophylaxis - child |
1,536 |
1,531 |
$51K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
480 |
185 |
$50K |
| D9999 |
Unspecified adjunctive procedure, by report |
88 |
78 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,669 |
1,661 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,424 |
1,422 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
162 |
$24K |
| D0272 |
Bitewings - two radiographic images |
941 |
937 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
129 |
$18K |
| D2332 |
|
129 |
63 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
393 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
157 |
$11K |
| D1351 |
Sealant - per tooth |
203 |
96 |
$10K |
| D0330 |
Panoramic radiographic image |
175 |
173 |
$10K |
| D0274 |
Bitewings - four radiographic images |
278 |
275 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
307 |
280 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
653 |
650 |
$9K |
| D2330 |
|
99 |
60 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
58 |
$7K |
| D1510 |
|
28 |
24 |
$5K |
| D1110 |
Prophylaxis - adult |
113 |
111 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
103 |
99 |
$2K |