| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
729 |
729 |
$20K |
| D1120 |
Prophylaxis - child |
653 |
653 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
128 |
$17K |
| D1351 |
Sealant - per tooth |
768 |
190 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
709 |
709 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
85 |
$9K |
| D0274 |
Bitewings - four radiographic images |
238 |
238 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
383 |
$4K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$4K |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
276 |
275 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$950.20 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
22 |
$545.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$256.88 |
| D0603 |
|
20 |
20 |
$200.00 |