| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,424 |
2,424 |
$173K |
| D1110 |
Prophylaxis - adult |
1,697 |
1,697 |
$161K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
341 |
207 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
101 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
40 |
$5K |
| D1351 |
Sealant - per tooth |
3,216 |
931 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,658 |
1,658 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
3,805 |
3,805 |
$750.24 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$593.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,691 |
3,691 |
$43.23 |
| D0272 |
Bitewings - two radiographic images |
1,986 |
1,984 |
$31.74 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
316 |
313 |
$0.00 |