| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
73 |
15 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
235 |
$6K |
| D1120 |
Prophylaxis - child |
159 |
146 |
$5K |
| D1206 |
Topical application of fluoride varnish |
239 |
224 |
$4K |
| D0272 |
Bitewings - two radiographic images |
148 |
138 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0240 |
|
60 |
32 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
33 |
$851.20 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$444.60 |
| D0603 |
|
91 |
91 |
$315.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D0601 |
|
18 |
18 |
$0.00 |