| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
45 |
45 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
26 |
$642.60 |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$589.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$474.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$269.30 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$260.00 |