| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
398 |
398 |
$12K |
| D1206 |
Topical application of fluoride varnish |
409 |
408 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
70 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
277 |
$6K |
| D1351 |
Sealant - per tooth |
159 |
43 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
74 |
68 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
121 |
$3K |
| D1330 |
|
151 |
151 |
$2K |
| D1310 |
|
151 |
151 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
59 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$980.10 |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
94 |
$759.20 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$439.20 |