| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,850 |
548 |
$193K |
| D1120 |
Prophylaxis - child |
3,402 |
2,785 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,941 |
3,219 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
3,145 |
2,552 |
$55K |
| D1351 |
Sealant - per tooth |
1,872 |
271 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,908 |
1,556 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,271 |
952 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
737 |
$28K |
| D1110 |
Prophylaxis - adult |
648 |
515 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,958 |
1,444 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
343 |
156 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,066 |
1,603 |
$14K |
| D0330 |
Panoramic radiographic image |
323 |
249 |
$12K |
| D0274 |
Bitewings - four radiographic images |
158 |
151 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
157 |
113 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
45 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$126.48 |