| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,065 |
1,059 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,334 |
1,326 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
591 |
511 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,069 |
1,061 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
70 |
$9K |
| D9920 |
|
103 |
100 |
$5K |
| D0272 |
Bitewings - two radiographic images |
443 |
443 |
$5K |
| D1110 |
Prophylaxis - adult |
163 |
163 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
472 |
430 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
485 |
482 |
$3K |
| D1351 |
Sealant - per tooth |
36 |
14 |
$2K |
| D0240 |
|
90 |
46 |
$510.40 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
99 |
26 |
$0.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
13 |
$0.00 |