| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
144 |
38 |
$17K |
| D1120 |
Prophylaxis - child |
356 |
343 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
295 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
70 |
66 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
454 |
437 |
$6K |
| D0240 |
|
484 |
217 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
127 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
116 |
$3K |
| D0272 |
Bitewings - two radiographic images |
137 |
129 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
220 |
$2K |
| D1110 |
Prophylaxis - adult |
51 |
49 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
83 |
$1K |
| D9248 |
|
14 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
54 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
26 |
$677.75 |
| D0274 |
Bitewings - four radiographic images |
14 |
13 |
$415.32 |
| D0603 |
|
749 |
696 |
$0.00 |