| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,839 |
3,795 |
$72K |
| D1110 |
Prophylaxis - adult |
1,684 |
1,667 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
3,559 |
3,525 |
$63K |
| D1120 |
Prophylaxis - child |
1,236 |
1,211 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,036 |
1,029 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,025 |
1,004 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
904 |
864 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
13 |
$6K |
| D9630 |
|
280 |
280 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
113 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
26 |
$3K |
| D9994 |
|
480 |
453 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$701.87 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$539.84 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$374.22 |