| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
161 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
32 |
$7K |
| D1351 |
Sealant - per tooth |
185 |
52 |
$6K |
| D1120 |
Prophylaxis - child |
143 |
143 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
126 |
109 |
$4K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$4K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$3K |
| D0240 |
|
107 |
56 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
47 |
$2K |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
80 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$660.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
23 |
$455.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$416.00 |