| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
247 |
247 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
13 |
$9K |
| D7111 |
|
41 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
184 |
$901.80 |
| D1206 |
Topical application of fluoride varnish |
117 |
117 |
$506.85 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$423.61 |
| D1330 |
|
282 |
282 |
$419.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$245.25 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
95 |
$168.77 |
| D0272 |
Bitewings - two radiographic images |
77 |
77 |
$93.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
24 |
$60.80 |
| D9420 |
|
15 |
15 |
$0.00 |