| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
102 |
55 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
109 |
91 |
$9K |
| D1110 |
Prophylaxis - adult |
139 |
138 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
249 |
$6K |
| D0272 |
Bitewings - two radiographic images |
207 |
207 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
157 |
153 |
$4K |
| D1206 |
Topical application of fluoride varnish |
206 |
206 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
222 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
206 |
$3K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$3K |
| D2140 |
|
40 |
30 |
$3K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |