| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
294 |
292 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
311 |
309 |
$3K |
| D1351 |
Sealant - per tooth |
169 |
50 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
401 |
399 |
$334.43 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$295.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$239.31 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
56 |
48 |
$179.85 |
| D0272 |
Bitewings - two radiographic images |
208 |
206 |
$66.90 |
| D0240 |
|
100 |
90 |
$66.88 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
47 |
$17.85 |
| D1330 |
|
376 |
374 |
$0.00 |