| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
362 |
361 |
$14K |
| D1206 |
Topical application of fluoride varnish |
465 |
464 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
359 |
358 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
115 |
110 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
41 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
54 |
53 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$1K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
107 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
65 |
$469.00 |
| D0603 |
|
37 |
37 |
$350.00 |