| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,145 |
278 |
$147K |
| D1120 |
Prophylaxis - child |
2,014 |
1,967 |
$62K |
| D1351 |
Sealant - per tooth |
2,047 |
379 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,962 |
1,919 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
901 |
871 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
643 |
642 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
330 |
317 |
$14K |
| D0272 |
Bitewings - two radiographic images |
731 |
710 |
$11K |
| D0240 |
|
1,279 |
567 |
$9K |
| D1999 |
|
765 |
711 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
300 |
276 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
228 |
203 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,267 |
467 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
620 |
588 |
$4K |
| D9420 |
|
26 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
55 |
$2K |