| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,178 |
1,178 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,059 |
1,059 |
$16K |
| D1206 |
Topical application of fluoride varnish |
466 |
463 |
$9K |
| D1354 |
|
325 |
81 |
$7K |
| D0272 |
Bitewings - two radiographic images |
798 |
798 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
846 |
846 |
$5K |
| D1351 |
Sealant - per tooth |
176 |
55 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
26 |
$949.16 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$923.00 |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$818.77 |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
108 |
$572.96 |
| D1330 |
|
801 |
801 |
$0.00 |
| D9215 |
|
66 |
65 |
$0.00 |
| D9630 |
|
76 |
75 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
213 |
204 |
$0.00 |
| D1999 |
|
120 |
113 |
$0.00 |