| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,162 |
1,150 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
243 |
74 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
708 |
707 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
592 |
566 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
970 |
966 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
330 |
306 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
294 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
57 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
662 |
258 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
619 |
604 |
$4K |
| D1206 |
Topical application of fluoride varnish |
739 |
724 |
$2K |
| D1110 |
Prophylaxis - adult |
139 |
134 |
$2K |
| D0272 |
Bitewings - two radiographic images |
164 |
161 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$2K |
| D9630 |
|
108 |
108 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |