| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
79 |
33 |
$17K |
| D1120 |
Prophylaxis - child |
218 |
218 |
$11K |
| D1206 |
Topical application of fluoride varnish |
212 |
212 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
480 |
160 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
191 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
49 |
$3K |
| D0240 |
|
189 |
106 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$3K |
| D9986 |
|
73 |
68 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
50 |
$0.00 |