| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
387 |
387 |
$25K |
| D1120 |
Prophylaxis - child |
401 |
401 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
88 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,999 |
375 |
$8K |
| D1310 |
|
170 |
170 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
157 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
205 |
$4K |
| D1351 |
Sealant - per tooth |
91 |
24 |
$4K |
| D0272 |
Bitewings - two radiographic images |
294 |
291 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
18 |
$3K |
| D0603 |
|
136 |
136 |
$2K |
| D1206 |
Topical application of fluoride varnish |
119 |
119 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D0340 |
|
28 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$1K |
| D0350 |
|
83 |
32 |
$796.80 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |