| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
851 |
851 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
763 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
169 |
57 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
505 |
505 |
$12K |
| D0272 |
Bitewings - two radiographic images |
344 |
344 |
$9K |
| D1206 |
Topical application of fluoride varnish |
299 |
298 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
389 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
140 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
53 |
$2K |
| D9920 |
|
27 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$845.00 |