| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,115 |
751 |
$308K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,418 |
1,386 |
$196K |
| D1120 |
Prophylaxis - child |
4,625 |
4,563 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,602 |
770 |
$153K |
| D9248 |
|
1,167 |
1,096 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
4,656 |
4,595 |
$131K |
| D1351 |
Sealant - per tooth |
3,594 |
1,050 |
$100K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,222 |
735 |
$93K |
| D0272 |
Bitewings - two radiographic images |
3,762 |
3,710 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,440 |
5,381 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
733 |
726 |
$50K |
| D1110 |
Prophylaxis - adult |
824 |
818 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
601 |
325 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
662 |
641 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
880 |
847 |
$22K |
| D0274 |
Bitewings - four radiographic images |
530 |
526 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,414 |
1,362 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,019 |
808 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$694.86 |
| D0603 |
|
7,097 |
6,996 |
$0.00 |