| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,155 |
2,155 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,011 |
2,010 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,167 |
2,165 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
171 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,203 |
1,203 |
$23K |
| D1351 |
Sealant - per tooth |
526 |
162 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
450 |
432 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
169 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
141 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
416 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
290 |
128 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$699.70 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$391.05 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$320.03 |