| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,056 |
1,054 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
900 |
899 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,024 |
1,023 |
$21K |
| D0272 |
Bitewings - two radiographic images |
398 |
397 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
837 |
246 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
12 |
$7K |
| D0603 |
|
1,011 |
1,009 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
355 |
347 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
90 |
$4K |
| D0240 |
|
131 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D1354 |
|
214 |
103 |
$464.73 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$448.50 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$442.75 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$366.85 |
| D0602 |
|
25 |
25 |
$139.15 |