| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
515 |
121 |
$58K |
| D1206 |
Topical application of fluoride varnish |
864 |
806 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
617 |
617 |
$13K |
| D1120 |
Prophylaxis - child |
519 |
519 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
79 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
247 |
237 |
$6K |
| D0272 |
Bitewings - two radiographic images |
436 |
436 |
$5K |
| D1351 |
Sealant - per tooth |
152 |
52 |
$4K |
| D2934 |
|
28 |
12 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D9420 |
|
15 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
49 |
$565.00 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
83 |
$480.00 |
| D0240 |
|
71 |
38 |
$476.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$396.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$264.00 |