| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9248 |
|
114 |
114 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
209 |
86 |
$23K |
| D1120 |
Prophylaxis - child |
558 |
555 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
641 |
638 |
$19K |
| D1206 |
Topical application of fluoride varnish |
728 |
725 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
81 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
110 |
59 |
$9K |
| D0272 |
Bitewings - two radiographic images |
293 |
291 |
$6K |
| D1110 |
Prophylaxis - adult |
106 |
106 |
$6K |
| D2140 |
|
72 |
43 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
78 |
77 |
$4K |
| D1510 |
|
20 |
15 |
$4K |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$3K |
| D2330 |
|
23 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
73 |
$739.00 |