| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,366 |
1,230 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,067 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,132 |
1,004 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,564 |
1,424 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
705 |
645 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
263 |
208 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
164 |
121 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,735 |
1,548 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
362 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
170 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
91 |
$6K |
| D1354 |
|
30 |
14 |
$608.85 |
| D0272 |
Bitewings - two radiographic images |
52 |
42 |
$470.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$162.00 |