| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
688 |
380 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,322 |
3,288 |
$86K |
| D9248 |
|
729 |
681 |
$68K |
| D1120 |
Prophylaxis - child |
1,912 |
1,894 |
$67K |
| D1110 |
Prophylaxis - adult |
1,303 |
1,287 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,973 |
2,943 |
$57K |
| D0272 |
Bitewings - two radiographic images |
2,156 |
2,137 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,589 |
1,464 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
254 |
253 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,025 |
1,000 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,399 |
647 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
66 |
$8K |
| D1351 |
Sealant - per tooth |
283 |
84 |
$8K |
| D0601 |
|
1,239 |
1,230 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
148 |
$5K |
| D2140 |
|
31 |
17 |
$2K |
| D0330 |
Panoramic radiographic image |
80 |
77 |
$2K |
| D0602 |
|
309 |
304 |
$2K |
| D7111 |
|
30 |
14 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$1K |
| D0603 |
|
128 |
126 |
$595.52 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$339.15 |