| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,484 |
1,484 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
698 |
698 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
634 |
634 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
355 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,255 |
1,255 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
632 |
563 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,203 |
1,353 |
$18K |
| D0272 |
Bitewings - two radiographic images |
684 |
683 |
$8K |
| D0274 |
Bitewings - four radiographic images |
316 |
316 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
65 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
51 |
51 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
178 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |