| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
269 |
269 |
$15K |
| D1206 |
Topical application of fluoride varnish |
324 |
324 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
251 |
222 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
262 |
$7K |
| D0272 |
Bitewings - two radiographic images |
154 |
154 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
12 |
$6K |
| D1351 |
Sealant - per tooth |
106 |
38 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
107 |
107 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
43 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$1K |
| D9222 |
|
12 |
12 |
$575.70 |