| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,524 |
2,007 |
$165K |
| D0999 |
Unspecified diagnostic procedure, by report |
550 |
444 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,144 |
1,028 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
71 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
2,128 |
951 |
$233.84 |
| D0272 |
Bitewings - two radiographic images |
855 |
398 |
$116.92 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
26 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
158 |
87 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
27 |
$0.00 |