| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
590 |
568 |
$250K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
34 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
29 |
$5K |
| D1206 |
Topical application of fluoride varnish |
400 |
399 |
$2K |
| D1120 |
Prophylaxis - child |
328 |
326 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
218 |
217 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$750.85 |
| D1351 |
Sealant - per tooth |
24 |
13 |
$618.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$556.20 |
| D1354 |
|
30 |
14 |
$224.20 |
| D1330 |
|
184 |
183 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$0.00 |