| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,763 |
401 |
$142K |
| D2933 |
|
937 |
197 |
$62K |
| D1120 |
Prophylaxis - child |
1,176 |
1,093 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,251 |
1,159 |
$51K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,334 |
307 |
$46K |
| D1351 |
Sealant - per tooth |
2,293 |
533 |
$36K |
| D3230 |
|
719 |
145 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
697 |
294 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
965 |
333 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
839 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,780 |
1,418 |
$13K |
| D9420 |
|
514 |
375 |
$13K |
| D0274 |
Bitewings - four radiographic images |
860 |
735 |
$12K |
| D0272 |
Bitewings - two radiographic images |
792 |
668 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
335 |
321 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,239 |
1,065 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
570 |
455 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
77 |
$6K |
| D0330 |
Panoramic radiographic image |
164 |
157 |
$6K |
| D9310 |
|
314 |
296 |
$6K |
| D0350 |
|
502 |
368 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
63 |
$3K |
| D1510 |
|
38 |
26 |
$3K |
| D7111 |
|
57 |
27 |
$2K |
| D1353 |
|
127 |
33 |
$2K |
| D2330 |
|
44 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
29 |
$963.96 |
| D0601 |
|
151 |
149 |
$690.00 |
| D0602 |
|
79 |
76 |
$345.00 |
| D3120 |
|
29 |
15 |
$54.00 |