| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
27 |
$18K |
| D1120 |
Prophylaxis - child |
428 |
400 |
$16K |
| D1206 |
Topical application of fluoride varnish |
458 |
430 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
329 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
227 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
83 |
$4K |
| D0272 |
Bitewings - two radiographic images |
104 |
104 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
44 |
$2K |
| D0240 |
|
52 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$702.00 |
| D0603 |
|
69 |
66 |
$345.00 |