| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
966 |
166 |
$137K |
| D0145 |
Oral evaluation for a patient under three years of age |
651 |
616 |
$85K |
| D1120 |
Prophylaxis - child |
2,184 |
2,050 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,558 |
2,413 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,805 |
2,640 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,955 |
1,846 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,215 |
3,008 |
$31K |
| D9248 |
|
252 |
240 |
$28K |
| D1110 |
Prophylaxis - adult |
573 |
538 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,182 |
2,832 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
132 |
$24K |
| D1351 |
Sealant - per tooth |
1,179 |
174 |
$22K |
| D0274 |
Bitewings - four radiographic images |
569 |
536 |
$15K |
| D0330 |
Panoramic radiographic image |
504 |
473 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
280 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
40 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$525.46 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$220.50 |
| D1999 |
|
2,815 |
2,604 |
$0.00 |
| D0603 |
|
3,979 |
3,754 |
$0.00 |