| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9630 |
|
772 |
765 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,241 |
1,227 |
$30K |
| D1120 |
Prophylaxis - child |
1,101 |
1,088 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
756 |
750 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
148 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
107 |
24 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
277 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,203 |
1,192 |
$10K |
| D0272 |
Bitewings - two radiographic images |
840 |
833 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,099 |
1,164 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
65 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
139 |
138 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
143 |
138 |
$4K |
| D0330 |
Panoramic radiographic image |
98 |
96 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
26 |
$3K |