| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
366 |
366 |
$10K |
| D1120 |
Prophylaxis - child |
311 |
311 |
$10K |
| D1206 |
Topical application of fluoride varnish |
277 |
277 |
$7K |
| D1351 |
Sealant - per tooth |
144 |
33 |
$6K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$4K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$3K |
| D0272 |
Bitewings - two radiographic images |
182 |
182 |
$3K |
| D0240 |
|
109 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
32 |
$990.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$865.37 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
15 |
$693.30 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
18 |
$106.00 |
| D1999 |
|
124 |
114 |
$0.00 |