| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
604 |
169 |
$70K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
141 |
130 |
$38K |
| D1120 |
Prophylaxis - child |
810 |
780 |
$23K |
| D1206 |
Topical application of fluoride varnish |
967 |
918 |
$16K |
| D0272 |
Bitewings - two radiographic images |
817 |
744 |
$15K |
| D0240 |
|
750 |
376 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
148 |
68 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
534 |
$11K |
| D9222 |
|
119 |
116 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
251 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
51 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
43 |
$5K |
| D9310 |
|
151 |
144 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
218 |
173 |
$4K |
| D9610 |
|
133 |
130 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$1K |
| D1351 |
Sealant - per tooth |
32 |
13 |
$697.76 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
34 |
$392.00 |