| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,453 |
1,451 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
184 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
128 |
29 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
63 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$629.40 |
| D0220 |
Intraoral - periapical first radiographic image |
1,314 |
1,293 |
$241.94 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$160.94 |
| D0120 |
Periodic oral evaluation - established patient |
1,247 |
1,247 |
$143.26 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
148 |
136 |
$47.87 |
| D0272 |
Bitewings - two radiographic images |
776 |
776 |
$17.16 |
| D1206 |
Topical application of fluoride varnish |
490 |
490 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
873 |
872 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,122 |
1,176 |
$0.00 |
| D1351 |
Sealant - per tooth |
97 |
26 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$0.00 |