| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
164 |
162 |
$7K |
| D1206 |
Topical application of fluoride varnish |
141 |
139 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
36 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
57 |
$689.92 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
85 |
$557.83 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$267.68 |