| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,146 |
3,146 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
4,200 |
4,200 |
$119K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
638 |
591 |
$96K |
| D1110 |
Prophylaxis - adult |
1,200 |
1,200 |
$65K |
| D1351 |
Sealant - per tooth |
1,363 |
392 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,379 |
3,379 |
$48K |
| D0330 |
Panoramic radiographic image |
524 |
524 |
$26K |
| D1206 |
Topical application of fluoride varnish |
894 |
894 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
207 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,055 |
1,055 |
$22K |
| D0274 |
Bitewings - four radiographic images |
249 |
249 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
50 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
217 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$530.10 |
| D1999 |
|
604 |
586 |
$0.00 |