| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
196 |
47 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
153 |
152 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
294 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
974 |
341 |
$10K |
| D1120 |
Prophylaxis - child |
275 |
263 |
$9K |
| D1351 |
Sealant - per tooth |
214 |
54 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
397 |
368 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
38 |
$4K |
| D9248 |
|
28 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
77 |
76 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
115 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
48 |
47 |
$1K |
| D1206 |
Topical application of fluoride varnish |
76 |
74 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
28 |
$759.08 |
| D0350 |
|
19 |
18 |
$91.90 |
| D0603 |
|
608 |
584 |
$0.00 |