| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
124 |
91 |
$20K |
| D1120 |
Prophylaxis - child |
421 |
420 |
$19K |
| D1351 |
Sealant - per tooth |
387 |
62 |
$13K |
| D1206 |
Topical application of fluoride varnish |
464 |
463 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$11K |
| D0330 |
Panoramic radiographic image |
88 |
87 |
$5K |
| D0272 |
Bitewings - two radiographic images |
148 |
148 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
114 |
106 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$4K |
| D7111 |
|
19 |
13 |
$2K |