| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
642 |
131 |
$86K |
| D1120 |
Prophylaxis - child |
1,199 |
1,139 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,351 |
1,297 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
255 |
250 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
234 |
125 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
285 |
161 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,453 |
1,388 |
$19K |
| D1351 |
Sealant - per tooth |
668 |
201 |
$16K |
| D1110 |
Prophylaxis - adult |
283 |
274 |
$14K |
| D0272 |
Bitewings - two radiographic images |
641 |
605 |
$13K |
| D0240 |
|
1,544 |
729 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
275 |
94 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
284 |
249 |
$7K |
| D9248 |
|
40 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
302 |
$4K |
| D0330 |
Panoramic radiographic image |
55 |
49 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
150 |
$3K |
| D0274 |
Bitewings - four radiographic images |
80 |
78 |
$3K |
| D9420 |
|
73 |
70 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
72 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
77 |
$1K |
| D0603 |
|
1,863 |
1,768 |
$0.00 |