| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
304 |
67 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
743 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,549 |
730 |
$16K |
| D1120 |
Prophylaxis - child |
437 |
425 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
855 |
813 |
$10K |
| D0272 |
Bitewings - two radiographic images |
452 |
429 |
$10K |
| D2934 |
|
61 |
12 |
$9K |
| D1351 |
Sealant - per tooth |
331 |
86 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
39 |
$8K |
| D1206 |
Topical application of fluoride varnish |
508 |
496 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
190 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
26 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
53 |
$1K |
| D0350 |
|
24 |
24 |
$220.56 |
| D0603 |
|
1,036 |
1,021 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |