| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
463 |
107 |
$65K |
| D1120 |
Prophylaxis - child |
776 |
755 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
668 |
$19K |
| D0272 |
Bitewings - two radiographic images |
697 |
680 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
106 |
104 |
$14K |
| D1206 |
Topical application of fluoride varnish |
845 |
823 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
516 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
219 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
613 |
600 |
$7K |
| D1351 |
Sealant - per tooth |
234 |
63 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
126 |
120 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D9420 |
|
12 |
12 |
$435.72 |
| D0602 |
|
138 |
136 |
$0.00 |
| D0603 |
|
879 |
862 |
$0.00 |