| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,463 |
2,463 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,587 |
2,586 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
275 |
272 |
$38K |
| D1351 |
Sealant - per tooth |
998 |
282 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,333 |
1,333 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,769 |
1,769 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
263 |
$33K |
| D1110 |
Prophylaxis - adult |
577 |
577 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,975 |
1,975 |
$27K |
| D0330 |
Panoramic radiographic image |
407 |
407 |
$19K |
| D0274 |
Bitewings - four radiographic images |
489 |
489 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
116 |
$16K |
| D1354 |
|
238 |
60 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
209 |
209 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
36 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
79 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$692.43 |