| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$4K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
17 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$3K |
| D1351 |
Sealant - per tooth |
68 |
20 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
17 |
$2K |
| D8660 |
|
12 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
97 |
97 |
$2K |
| D0340 |
|
25 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
34 |
$1K |
| D0240 |
|
25 |
25 |
$967.73 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$605.22 |