| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,130 |
1,130 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,252 |
1,252 |
$23K |
| D9630 |
|
571 |
571 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,110 |
1,110 |
$16K |
| D0272 |
Bitewings - two radiographic images |
792 |
792 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,188 |
1,186 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
101 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,140 |
1,140 |
$10K |
| D1351 |
Sealant - per tooth |
400 |
122 |
$9K |
| D0274 |
Bitewings - four radiographic images |
335 |
335 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
158 |
$8K |
| D1110 |
Prophylaxis - adult |
252 |
252 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
24 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
167 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
46 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
95 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
32 |
$612.78 |