| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,150 |
237 |
$154K |
| D1351 |
Sealant - per tooth |
1,763 |
300 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
382 |
121 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,491 |
1,048 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,022 |
975 |
$32K |
| D0145 |
Oral evaluation for a patient under three years of age |
154 |
152 |
$21K |
| D1120 |
Prophylaxis - child |
550 |
533 |
$18K |
| D9248 |
|
160 |
148 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,196 |
1,131 |
$11K |
| D1206 |
Topical application of fluoride varnish |
683 |
663 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
63 |
$8K |
| D0272 |
Bitewings - two radiographic images |
368 |
348 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
217 |
208 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
133 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$3K |
| D0330 |
Panoramic radiographic image |
230 |
217 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
13 |
$1K |
| D0603 |
|
1,542 |
1,473 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |