| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
16 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
170 |
$4K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
152 |
151 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
19 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
115 |
$2K |
| D1110 |
Prophylaxis - adult |
43 |
42 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
75 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
51 |
$842.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
21 |
$570.00 |
| D9248 |
|
20 |
20 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |