| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
377 |
76 |
$75K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
244 |
44 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
33 |
$9K |
| D1120 |
Prophylaxis - child |
150 |
148 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
421 |
126 |
$6K |
| D9222 |
|
46 |
42 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
57 |
$4K |
| D1206 |
Topical application of fluoride varnish |
120 |
119 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
139 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
39 |
39 |
$1K |
| D9310 |
|
14 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
32 |
13 |
$918.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
19 |
$570.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$444.00 |