| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
344 |
344 |
$15K |
| D1206 |
Topical application of fluoride varnish |
342 |
342 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
289 |
289 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
46 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
49 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
182 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
193 |
167 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$980.00 |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$587.77 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$362.60 |