| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
395 |
395 |
$15K |
| D1206 |
Topical application of fluoride varnish |
407 |
407 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
380 |
380 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
44 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
62 |
$5K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
87 |
86 |
$3K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$935.00 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$822.00 |
| D0240 |
|
12 |
12 |
$456.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$383.00 |