| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
503 |
501 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
514 |
511 |
$13K |
| D1206 |
Topical application of fluoride varnish |
567 |
564 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
56 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
118 |
114 |
$4K |
| D0272 |
Bitewings - two radiographic images |
153 |
152 |
$3K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
115 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$975.00 |
| D1351 |
Sealant - per tooth |
47 |
13 |
$897.00 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$525.60 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
21 |
$462.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
13 |
$154.20 |