| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,184 |
6,175 |
$310K |
| D1206 |
Topical application of fluoride varnish |
6,160 |
6,147 |
$108K |
| D9999 |
Unspecified adjunctive procedure, by report |
4,264 |
4,232 |
$78K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
348 |
235 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
825 |
824 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
490 |
488 |
$19K |
| D9920 |
|
45 |
45 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,212 |
575 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
56 |
$4K |
| D0272 |
Bitewings - two radiographic images |
338 |
338 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
29 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$2K |
| D9420 |
|
27 |
12 |
$2K |
| D1354 |
|
485 |
111 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$612.00 |
| D1310 |
|
54 |
54 |
$0.00 |