| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
210 |
50 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,075 |
1,059 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
603 |
577 |
$30K |
| D1120 |
Prophylaxis - child |
1,062 |
1,038 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
544 |
542 |
$19K |
| D9999 |
Unspecified adjunctive procedure, by report |
516 |
504 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
210 |
187 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
548 |
524 |
$5K |
| D0272 |
Bitewings - two radiographic images |
396 |
388 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
27 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
122 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
900 |
448 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
33 |
$877.80 |