| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
930 |
212 |
$129K |
| D1206 |
Topical application of fluoride varnish |
3,877 |
3,784 |
$71K |
| D1120 |
Prophylaxis - child |
3,253 |
3,198 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,668 |
2,659 |
$67K |
| D2929 |
|
219 |
56 |
$46K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
321 |
109 |
$30K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,110 |
1,095 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
601 |
580 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
366 |
183 |
$21K |
| D1351 |
Sealant - per tooth |
887 |
231 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
805 |
722 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
823 |
753 |
$16K |
| D9920 |
|
660 |
637 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,737 |
1,682 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
109 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,280 |
1,254 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,706 |
1,629 |
$9K |
| D0240 |
|
772 |
740 |
$7K |
| D7961 |
|
53 |
50 |
$5K |
| D1999 |
|
356 |
329 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
43 |
$4K |
| D1354 |
|
548 |
61 |
$2K |
| D7962 |
|
14 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
17 |
$663.09 |