| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,843 |
2,834 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
2,560 |
2,554 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
648 |
225 |
$65K |
| D1206 |
Topical application of fluoride varnish |
2,969 |
2,961 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
354 |
188 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,257 |
1,253 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
391 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
277 |
272 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
450 |
443 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
219 |
$2K |
| D0603 |
|
2,047 |
2,040 |
$871.00 |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$624.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |
| D1354 |
|
57 |
24 |
$336.00 |
| D0602 |
|
75 |
75 |
$50.00 |
| D0601 |
|
64 |
64 |
$0.00 |