| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,706 |
498 |
$168K |
| D1120 |
Prophylaxis - child |
3,807 |
3,735 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,990 |
3,913 |
$63K |
| D1206 |
Topical application of fluoride varnish |
4,154 |
4,080 |
$57K |
| D0272 |
Bitewings - two radiographic images |
1,394 |
1,359 |
$21K |
| D1110 |
Prophylaxis - adult |
379 |
371 |
$13K |
| D1351 |
Sealant - per tooth |
480 |
84 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
198 |
183 |
$4K |
| D9310 |
|
127 |
126 |
$3K |
| D0240 |
|
144 |
87 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
152 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$946.83 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$687.96 |
| D9420 |
|
12 |
12 |
$491.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
13 |
$384.46 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
15 |
$353.10 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$306.02 |
| D1999 |
|
459 |
424 |
$0.00 |