| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
366 |
90 |
$54K |
| D1120 |
Prophylaxis - child |
2,379 |
2,260 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,369 |
2,245 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,692 |
1,616 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
692 |
647 |
$26K |
| D9999 |
Unspecified adjunctive procedure, by report |
566 |
545 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,919 |
1,758 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,187 |
1,115 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,757 |
1,580 |
$10K |
| D1351 |
Sealant - per tooth |
359 |
100 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
77 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
38 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
226 |
206 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
25 |
$3K |
| D1999 |
|
243 |
202 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
51 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
49 |
$1K |