| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
179 |
179 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
194 |
$6K |
| D1206 |
Topical application of fluoride varnish |
191 |
191 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
12 |
$5K |
| D0240 |
|
119 |
82 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
17 |
$3K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$2K |
| D1351 |
Sealant - per tooth |
49 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
22 |
22 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$543.60 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$477.33 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$346.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$345.80 |