| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,060 |
253 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
856 |
378 |
$82K |
| D0145 |
Oral evaluation for a patient under three years of age |
502 |
486 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,167 |
2,084 |
$59K |
| D1120 |
Prophylaxis - child |
1,540 |
1,492 |
$54K |
| D1351 |
Sealant - per tooth |
1,790 |
413 |
$48K |
| D1110 |
Prophylaxis - adult |
713 |
686 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,398 |
2,305 |
$33K |
| D0274 |
Bitewings - four radiographic images |
874 |
841 |
$29K |
| D0272 |
Bitewings - two radiographic images |
944 |
908 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
625 |
580 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
750 |
707 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
201 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
99 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
656 |
284 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
318 |
303 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
29 |
$5K |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$765.36 |
| D0603 |
|
3,032 |
2,911 |
$0.00 |
| D0601 |
|
49 |
47 |
$0.00 |