| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,957 |
1,910 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
1,591 |
1,550 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,863 |
1,812 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
107 |
$2K |
| D1351 |
Sealant - per tooth |
450 |
95 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
407 |
$1K |
| D0272 |
Bitewings - two radiographic images |
655 |
642 |
$999.55 |
| D0240 |
|
499 |
437 |
$893.55 |
| D0330 |
Panoramic radiographic image |
114 |
107 |
$566.71 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
207 |
196 |
$223.92 |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
199 |
$114.77 |
| D0274 |
Bitewings - four radiographic images |
85 |
83 |
$85.12 |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
12 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |