| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
179 |
41 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
186 |
178 |
$24K |
| D1120 |
Prophylaxis - child |
642 |
615 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
593 |
568 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
59 |
$10K |
| D1206 |
Topical application of fluoride varnish |
708 |
683 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
65 |
$8K |
| D0240 |
|
825 |
399 |
$7K |
| D0272 |
Bitewings - two radiographic images |
241 |
231 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
106 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
101 |
91 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
168 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
59 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
27 |
$507.06 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$484.54 |
| D0603 |
|
960 |
933 |
$0.00 |
| D1999 |
|
120 |
111 |
$0.00 |