| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
664 |
664 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
699 |
699 |
$19K |
| D1206 |
Topical application of fluoride varnish |
625 |
625 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
60 |
13 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
338 |
328 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
29 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
308 |
308 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
176 |
176 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
26 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$670.90 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$507.59 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$378.28 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$338.48 |