| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
122 |
39 |
$24K |
| D1206 |
Topical application of fluoride varnish |
578 |
534 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
61 |
$14K |
| D1120 |
Prophylaxis - child |
470 |
439 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
195 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
210 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
205 |
189 |
$7K |
| D9630 |
|
129 |
123 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
295 |
$3K |
| D1351 |
Sealant - per tooth |
49 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
150 |
139 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D9248 |
|
20 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
584 |
260 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
48 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$747.04 |
| D0330 |
Panoramic radiographic image |
17 |
14 |
$595.70 |