| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,237 |
1,213 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
173 |
38 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,090 |
1,080 |
$24K |
| D9920 |
|
1,020 |
847 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,453 |
1,438 |
$23K |
| D1330 |
|
971 |
949 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
46 |
$859.28 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$686.88 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$672.18 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
15 |
$574.16 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$506.15 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
27 |
$376.32 |
| D9985 |
|
15 |
14 |
$0.00 |