| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
443 |
132 |
$88K |
| D7140 |
Extraction, erupted tooth or exposed root |
296 |
118 |
$27K |
| D1120 |
Prophylaxis - child |
385 |
384 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
256 |
251 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,169 |
517 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
276 |
$15K |
| D1351 |
Sealant - per tooth |
412 |
96 |
$12K |
| D1206 |
Topical application of fluoride varnish |
353 |
352 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
565 |
557 |
$9K |
| D0272 |
Bitewings - two radiographic images |
356 |
353 |
$6K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$2K |
| D9310 |
|
13 |
13 |
$958.38 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
112 |
106 |
$0.00 |