| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
275 |
274 |
$8K |
| D1120 |
Prophylaxis - child |
250 |
250 |
$5K |
| D1206 |
Topical application of fluoride varnish |
334 |
334 |
$5K |
| D1351 |
Sealant - per tooth |
153 |
50 |
$3K |
| D0272 |
Bitewings - two radiographic images |
266 |
266 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
34 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$2K |
| D1330 |
|
328 |
328 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
26 |
$1K |
| D0240 |
|
33 |
29 |
$233.07 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
44 |
$135.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$132.00 |
| D0603 |
|
16 |
16 |
$0.00 |