| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
406 |
88 |
$45K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
168 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
101 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
99 |
$18K |
| D1351 |
Sealant - per tooth |
740 |
186 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
466 |
444 |
$15K |
| D1120 |
Prophylaxis - child |
362 |
345 |
$12K |
| D9248 |
|
143 |
106 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
533 |
506 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
105 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
217 |
211 |
$6K |
| D0272 |
Bitewings - two radiographic images |
301 |
288 |
$5K |
| D0330 |
Panoramic radiographic image |
153 |
144 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
419 |
390 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
396 |
313 |
$3K |
| D1110 |
Prophylaxis - adult |
58 |
57 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
38 |
$1K |
| D0350 |
|
100 |
86 |
$1K |
| D1330 |
|
19 |
19 |
$110.25 |
| D0603 |
|
1,549 |
1,200 |
$0.00 |