| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
313 |
313 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
53 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
312 |
312 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
291 |
291 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
42 |
$5K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
84 |
82 |
$3K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
186 |
147 |
$2K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
172 |
$2K |
| D1354 |
|
111 |
27 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$814.06 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$695.24 |
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
34 |
$685.10 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$386.40 |
| D9994 |
|
100 |
100 |
$82.80 |