| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
659 |
201 |
$131K |
| D1351 |
Sealant - per tooth |
752 |
247 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
107 |
$23K |
| D1120 |
Prophylaxis - child |
493 |
489 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
110 |
$22K |
| D9420 |
|
99 |
99 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
82 |
$20K |
| D1206 |
Topical application of fluoride varnish |
724 |
710 |
$20K |
| D2940 |
|
236 |
95 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
357 |
322 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
420 |
415 |
$14K |
| D0272 |
Bitewings - two radiographic images |
248 |
247 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
138 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
207 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
52 |
$3K |
| D2330 |
|
30 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
148 |
118 |
$2K |
| D0240 |
|
36 |
18 |
$904.64 |
| D1310 |
|
369 |
356 |
$0.00 |
| D1330 |
|
578 |
556 |
$0.00 |
| D0603 |
|
433 |
429 |
$0.00 |
| D9310 |
|
51 |
51 |
$0.00 |
| D3120 |
|
20 |
15 |
$0.00 |
| D9430 |
|
72 |
72 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
153 |
150 |
$0.00 |
| D1354 |
|
1,156 |
216 |
$0.00 |