| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,317 |
1,317 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,169 |
1,169 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
736 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
584 |
584 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,417 |
1,165 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,226 |
1,212 |
$21K |
| D0272 |
Bitewings - two radiographic images |
808 |
808 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
146 |
88 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
191 |
$11K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
30 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
108 |
$4K |
| D1354 |
|
35 |
13 |
$378.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$230.55 |