| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
472 |
160 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,295 |
1,268 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
442 |
167 |
$35K |
| D1120 |
Prophylaxis - child |
1,579 |
1,537 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,529 |
1,494 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
850 |
835 |
$18K |
| D9999 |
Unspecified adjunctive procedure, by report |
444 |
439 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,392 |
1,339 |
$11K |
| D1351 |
Sealant - per tooth |
399 |
127 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
223 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
282 |
254 |
$7K |
| D0272 |
Bitewings - two radiographic images |
682 |
661 |
$6K |
| D1999 |
|
408 |
357 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,410 |
1,106 |
$3K |