| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,087 |
1,087 |
$72K |
| D1110 |
Prophylaxis - adult |
347 |
347 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
205 |
140 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
37 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
41 |
41 |
$3K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
411 |
80 |
$951.16 |
| D0120 |
Periodic oral evaluation - established patient |
1,156 |
1,156 |
$206.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
416 |
398 |
$105.96 |
| D0274 |
Bitewings - four radiographic images |
303 |
303 |
$80.47 |
| D0220 |
Intraoral - periapical first radiographic image |
1,226 |
1,222 |
$10.51 |
| D1206 |
Topical application of fluoride varnish |
1,462 |
1,462 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
868 |
868 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,360 |
1,156 |
$0.00 |
| D9986 |
|
118 |
116 |
$0.00 |