| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
110 |
30 |
$8K |
| D1120 |
Prophylaxis - child |
179 |
161 |
$7K |
| D1206 |
Topical application of fluoride varnish |
174 |
156 |
$5K |
| D3240 |
|
62 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
105 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
145 |
137 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
178 |
$3K |
| D0330 |
Panoramic radiographic image |
68 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
159 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
18 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
15 |
$1K |
| D9248 |
|
12 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
44 |
$929.28 |
| D0603 |
|
70 |
56 |
$50.00 |