| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
12 |
$10K |
| D1120 |
Prophylaxis - child |
180 |
180 |
$4K |
| D0272 |
Bitewings - two radiographic images |
86 |
85 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$870.00 |
| D0120 |
Periodic oral evaluation - established patient |
40 |
40 |
$845.32 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$722.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$395.30 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$0.00 |