| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
516 |
514 |
$43K |
| D1120 |
Prophylaxis - child |
668 |
667 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
98 |
$37K |
| D1206 |
Topical application of fluoride varnish |
730 |
726 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
58 |
17 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
43 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
126 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
99 |
$7K |
| D0272 |
Bitewings - two radiographic images |
199 |
198 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
292 |
290 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
234 |
$6K |
| D0603 |
|
364 |
363 |
$4K |
| D0240 |
|
104 |
59 |
$4K |
| D0274 |
Bitewings - four radiographic images |
34 |
33 |
$2K |
| D1354 |
|
65 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$961.27 |
| D3120 |
|
20 |
14 |
$0.00 |