| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
520 |
161 |
$43K |
| D1120 |
Prophylaxis - child |
1,262 |
1,248 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,179 |
1,171 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,638 |
1,542 |
$19K |
| D0272 |
Bitewings - two radiographic images |
750 |
742 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
83 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
148 |
146 |
$6K |
| D1351 |
Sealant - per tooth |
285 |
125 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
263 |
$2K |
| D0240 |
|
156 |
111 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$357.39 |