| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
459 |
393 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
503 |
430 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
300 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
203 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
220 |
158 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
93 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
31 |
$812.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$441.00 |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
31 |
$286.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$242.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
15 |
$120.00 |