| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
294 |
66 |
$41K |
| D1120 |
Prophylaxis - child |
1,151 |
1,139 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,227 |
1,216 |
$33K |
| D1351 |
Sealant - per tooth |
1,254 |
276 |
$33K |
| D0145 |
Oral evaluation for a patient under three years of age |
218 |
217 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,052 |
1,039 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,344 |
1,332 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,527 |
1,512 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,648 |
1,454 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
50 |
$9K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
144 |
143 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
99 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$2K |
| D9248 |
|
15 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
108 |
107 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$777.04 |
| D0603 |
|
1,892 |
1,873 |
$0.00 |