| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
249 |
83 |
$25K |
| D1120 |
Prophylaxis - child |
520 |
484 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
177 |
79 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
335 |
$8K |
| D1206 |
Topical application of fluoride varnish |
553 |
515 |
$8K |
| D0330 |
Panoramic radiographic image |
219 |
206 |
$7K |
| D1351 |
Sealant - per tooth |
248 |
63 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
263 |
213 |
$5K |
| D0272 |
Bitewings - two radiographic images |
269 |
250 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
168 |
$3K |
| D0240 |
|
75 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
59 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
36 |
$861.08 |
| D0140 |
Limited oral evaluation - problem focused |
34 |
27 |
$848.47 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
86 |
$819.77 |
| D0603 |
|
55 |
54 |
$0.00 |