| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
96 |
96 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
88 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
125 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
85 |
77 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$926.20 |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
152 |
$840.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
17 |
$802.10 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$782.40 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$162.00 |