| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
608 |
606 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
214 |
198 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
102 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
154 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
170 |
$2K |
| D1120 |
Prophylaxis - child |
383 |
380 |
$260.94 |
| D1206 |
Topical application of fluoride varnish |
399 |
396 |
$130.47 |
| D0274 |
Bitewings - four radiographic images |
77 |
75 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
63 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D0603 |
|
43 |
42 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |