| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,692 |
2,190 |
$823K |
| D2390 |
|
3,690 |
1,155 |
$818K |
| D1510 |
|
270 |
171 |
$180K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,609 |
2,000 |
$146K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,095 |
1,895 |
$134K |
| D9248 |
|
161 |
159 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,319 |
3,255 |
$97K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,406 |
1,406 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
3,289 |
3,217 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,192 |
3,120 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
242 |
155 |
$9K |
| D0272 |
Bitewings - two radiographic images |
2,927 |
2,866 |
$8K |
| D1351 |
Sealant - per tooth |
3,035 |
952 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
458 |
249 |
$5K |
| D2330 |
|
232 |
146 |
$1K |
| D3230 |
|
39 |
14 |
$257.50 |
| D1120 |
Prophylaxis - child |
78 |
77 |
$100.58 |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
79 |
$0.00 |