| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
411 |
284 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
79 |
71 |
$8K |
| D0274 |
Bitewings - four radiographic images |
222 |
154 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
209 |
161 |
$6K |
| D1110 |
Prophylaxis - adult |
80 |
50 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
198 |
$2K |
| D0272 |
Bitewings - two radiographic images |
132 |
78 |
$402.81 |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$364.14 |
| D1208 |
Topical application of fluoride, excluding varnish |
507 |
352 |
$206.60 |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
113 |
$197.72 |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$178.20 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$142.69 |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
81 |
$0.00 |
| D1330 |
|
489 |
335 |
$0.00 |