| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
568 |
107 |
$78K |
| D1120 |
Prophylaxis - child |
1,418 |
1,314 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,462 |
1,353 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,456 |
1,111 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,577 |
1,440 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,340 |
1,242 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
143 |
56 |
$11K |
| D1351 |
Sealant - per tooth |
366 |
97 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
13 |
$3K |
| D9420 |
|
71 |
59 |
$2K |
| D0272 |
Bitewings - two radiographic images |
88 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
38 |
$975.96 |
| D0140 |
Limited oral evaluation - problem focused |
59 |
58 |
$957.78 |
| D0603 |
|
1,732 |
1,575 |
$0.00 |
| D0602 |
|
60 |
60 |
$0.00 |