| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,722 |
288 |
$234K |
| D0120 |
Periodic oral evaluation - established patient |
3,385 |
3,242 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,874 |
3,674 |
$85K |
| D1120 |
Prophylaxis - child |
3,536 |
3,356 |
$79K |
| D0272 |
Bitewings - two radiographic images |
1,914 |
1,798 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
434 |
405 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,664 |
1,536 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
112 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
576 |
544 |
$12K |
| D9999 |
Unspecified adjunctive procedure, by report |
295 |
285 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
81 |
39 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
138 |
64 |
$7K |
| D1999 |
|
409 |
367 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
292 |
249 |
$5K |
| D1351 |
Sealant - per tooth |
247 |
60 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,368 |
1,150 |
$3K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$553.15 |