| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
556 |
556 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
584 |
584 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
118 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
267 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
378 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
212 |
206 |
$6K |
| D1351 |
Sealant - per tooth |
205 |
71 |
$5K |
| D0272 |
Bitewings - two radiographic images |
285 |
285 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
34 |
$2K |
| D0240 |
|
167 |
160 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
283 |
129 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
239 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$877.78 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$525.65 |
| D1999 |
|
41 |
41 |
$0.00 |