| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
206 |
205 |
$7K |
| D1206 |
Topical application of fluoride varnish |
207 |
206 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
12 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
138 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
32 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
55 |
$2K |
| D0272 |
Bitewings - two radiographic images |
69 |
68 |
$1K |
| D9248 |
|
13 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$462.12 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$458.06 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$218.52 |