| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
591 |
591 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
336 |
188 |
$23K |
| D1206 |
Topical application of fluoride varnish |
621 |
621 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
543 |
543 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
353 |
326 |
$9K |
| D9248 |
|
15 |
14 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
191 |
191 |
$2K |
| D1351 |
Sealant - per tooth |
83 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$825.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
92 |
$564.00 |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
100 |
$500.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$480.00 |
| D0603 |
|
20 |
20 |
$200.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$156.00 |
| D0602 |
|
16 |
16 |
$150.00 |