| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
135 |
25 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
147 |
$10K |
| D1120 |
Prophylaxis - child |
258 |
238 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
175 |
$7K |
| D1206 |
Topical application of fluoride varnish |
234 |
214 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
110 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
58 |
54 |
$968.36 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$791.84 |
| D9222 |
|
16 |
16 |
$0.00 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
32 |
16 |
$0.00 |