| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
450 |
110 |
$59K |
| D0145 |
Oral evaluation for a patient under three years of age |
329 |
324 |
$43K |
| D1120 |
Prophylaxis - child |
1,203 |
1,175 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
945 |
917 |
$25K |
| D1351 |
Sealant - per tooth |
1,017 |
223 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,033 |
997 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,312 |
1,278 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,014 |
716 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
313 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
846 |
815 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
50 |
$6K |
| D0330 |
Panoramic radiographic image |
128 |
122 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
105 |
98 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
26 |
$868.65 |
| D0602 |
|
261 |
257 |
$0.00 |
| D0603 |
|
1,461 |
1,429 |
$0.00 |