| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
742 |
106 |
$82K |
| D1120 |
Prophylaxis - child |
2,226 |
2,137 |
$63K |
| D1206 |
Topical application of fluoride varnish |
2,115 |
2,025 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
969 |
931 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,107 |
1,082 |
$30K |
| D0272 |
Bitewings - two radiographic images |
884 |
840 |
$17K |
| D0330 |
Panoramic radiographic image |
328 |
317 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
29 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
252 |
206 |
$6K |
| D0274 |
Bitewings - four radiographic images |
160 |
156 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
372 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
38 |
$795.58 |