| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
26 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
69 |
68 |
$4K |
| D1120 |
Prophylaxis - child |
99 |
97 |
$4K |
| D1206 |
Topical application of fluoride varnish |
100 |
98 |
$3K |
| D2140 |
|
28 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
51 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
36 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$830.88 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
71 |
$423.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
61 |
$365.02 |
| D0272 |
Bitewings - two radiographic images |
29 |
27 |
$305.94 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$237.80 |