| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
241 |
46 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
105 |
72 |
$555.96 |
| D1120 |
Prophylaxis - child |
15 |
14 |
$441.00 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
17 |
$432.75 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$280.56 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
21 |
$264.60 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
32 |
$257.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
32 |
$235.98 |
| D0170 |
|
62 |
39 |
$99.24 |
| D9310 |
|
13 |
12 |
$14.58 |
| D0602 |
|
16 |
16 |
$0.00 |
| D0603 |
|
20 |
12 |
$0.00 |