| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,211 |
3,210 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
3,387 |
3,387 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
650 |
484 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,655 |
2,654 |
$37K |
| D1110 |
Prophylaxis - adult |
513 |
513 |
$28K |
| D1206 |
Topical application of fluoride varnish |
895 |
895 |
$26K |
| D1351 |
Sealant - per tooth |
372 |
177 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,037 |
1,037 |
$17K |
| D0330 |
Panoramic radiographic image |
348 |
348 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
359 |
341 |
$12K |
| D0274 |
Bitewings - four radiographic images |
293 |
293 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
265 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
13 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
39 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
14 |
$881.25 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$323.98 |
| D1330 |
|
201 |
201 |
$0.00 |