| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,128 |
1,117 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,229 |
1,209 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,320 |
1,307 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
320 |
297 |
$15K |
| D0272 |
Bitewings - two radiographic images |
367 |
366 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
14 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
53 |
$5K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
120 |
$3K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
107 |
$971.85 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$584.00 |
| D0240 |
|
44 |
25 |
$510.00 |
| D1330 |
|
45 |
45 |
$450.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$338.00 |