| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9420 |
|
65 |
63 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
13 |
$4K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$702.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$660.00 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$418.60 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$304.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
14 |
$126.75 |