| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
810 |
810 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
173 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
754 |
754 |
$8K |
| D1206 |
Topical application of fluoride varnish |
840 |
840 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
93 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
322 |
281 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$891.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$884.00 |
| D0272 |
Bitewings - two radiographic images |
253 |
253 |
$865.00 |
| D1351 |
Sealant - per tooth |
132 |
37 |
$639.00 |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$550.00 |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
136 |
$285.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$250.00 |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$187.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$27.50 |