| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
846 |
836 |
$27K |
| D8670 |
Periodic orthodontic treatment visit |
442 |
412 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
947 |
938 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,510 |
1,490 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,418 |
1,379 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,129 |
842 |
$11K |
| D0160 |
|
671 |
659 |
$9K |
| D0460 |
|
826 |
771 |
$9K |
| D2950 |
|
175 |
162 |
$7K |
| D9248 |
|
65 |
57 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
46 |
12 |
$5K |
| D0272 |
Bitewings - two radiographic images |
280 |
274 |
$5K |
| D1110 |
Prophylaxis - adult |
77 |
74 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
90 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
112 |
$2K |
| D0270 |
|
349 |
341 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
67 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
127 |
120 |
$1K |
| D9310 |
|
12 |
12 |
$87.48 |
| D0603 |
|
1,815 |
1,802 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D0364 |
|
17 |
17 |
$0.00 |