| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
1,365 |
1,310 |
$164K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,475 |
561 |
$144K |
| D1120 |
Prophylaxis - child |
3,918 |
3,839 |
$113K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,815 |
897 |
$107K |
| D1206 |
Topical application of fluoride varnish |
5,704 |
5,567 |
$99K |
| D1351 |
Sealant - per tooth |
3,815 |
1,057 |
$94K |
| D9248 |
|
454 |
453 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,668 |
3,598 |
$73K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,113 |
576 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,151 |
1,125 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,953 |
1,917 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
607 |
401 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
336 |
207 |
$25K |
| D1110 |
Prophylaxis - adult |
587 |
581 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
317 |
239 |
$20K |
| D9110 |
|
596 |
569 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
760 |
$16K |
| D0330 |
Panoramic radiographic image |
397 |
396 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,503 |
697 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,337 |
1,295 |
$10K |
| D1510 |
|
82 |
54 |
$10K |
| D0240 |
|
711 |
462 |
$10K |
| D0603 |
|
916 |
894 |
$9K |
| D1330 |
|
921 |
898 |
$4K |
| D1354 |
|
371 |
130 |
$3K |
| D2330 |
|
50 |
30 |
$2K |
| D1310 |
|
279 |
277 |
$1K |
| D1999 |
|
30 |
27 |
$0.01 |