| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,042 |
321 |
$138K |
| D0145 |
Oral evaluation for a patient under three years of age |
431 |
424 |
$60K |
| D1120 |
Prophylaxis - child |
1,499 |
1,454 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,616 |
1,565 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,768 |
1,909 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,871 |
1,806 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,114 |
1,072 |
$24K |
| D1351 |
Sealant - per tooth |
854 |
122 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,102 |
2,015 |
$21K |
| D1110 |
Prophylaxis - adult |
411 |
399 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
248 |
126 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
278 |
134 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
544 |
437 |
$14K |
| D0330 |
Panoramic radiographic image |
392 |
379 |
$14K |
| D0274 |
Bitewings - four radiographic images |
409 |
397 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
234 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
40 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
151 |
$3K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$499.80 |
| D9420 |
|
12 |
12 |
$435.72 |
| D0601 |
|
460 |
454 |
$0.00 |
| D0602 |
|
1,072 |
1,040 |
$0.00 |
| D0603 |
|
768 |
735 |
$0.00 |