| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,142 |
1,140 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
524 |
524 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
390 |
200 |
$26K |
| D1310 |
|
609 |
608 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,103 |
1,101 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
386 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
418 |
371 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,422 |
780 |
$15K |
| D1351 |
Sealant - per tooth |
374 |
113 |
$14K |
| D0603 |
|
603 |
602 |
$8K |
| D0272 |
Bitewings - two radiographic images |
575 |
573 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
12 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
88 |
88 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$276.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$199.50 |
| D1330 |
|
45 |
45 |
$0.00 |