| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,390 |
409 |
$139K |
| D9920 |
|
964 |
931 |
$116K |
| D1120 |
Prophylaxis - child |
3,733 |
3,657 |
$107K |
| D9248 |
|
471 |
468 |
$89K |
| D1206 |
Topical application of fluoride varnish |
5,012 |
4,893 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,285 |
545 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,456 |
3,382 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
905 |
445 |
$57K |
| D1351 |
Sealant - per tooth |
1,750 |
530 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,625 |
1,605 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
562 |
551 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
268 |
137 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
815 |
805 |
$17K |
| D1110 |
Prophylaxis - adult |
475 |
470 |
$16K |
| D0330 |
Panoramic radiographic image |
356 |
342 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
150 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
108 |
$11K |
| D0603 |
|
800 |
776 |
$8K |
| D0240 |
|
512 |
313 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
785 |
760 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
587 |
286 |
$5K |
| D1330 |
|
802 |
778 |
$4K |
| D1510 |
|
25 |
16 |
$3K |
| D1310 |
|
321 |
316 |
$1K |
| D9110 |
|
27 |
27 |
$810.00 |
| D1354 |
|
52 |
14 |
$420.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$336.00 |
| D1999 |
|
12 |
12 |
$0.00 |