| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
621 |
$24K |
| D1120 |
Prophylaxis - child |
1,124 |
845 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
871 |
614 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
97 |
$18K |
| D1206 |
Topical application of fluoride varnish |
867 |
605 |
$14K |
| D0274 |
Bitewings - four radiographic images |
705 |
517 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
417 |
272 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
625 |
436 |
$5K |
| D0330 |
Panoramic radiographic image |
157 |
108 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
88 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
42 |
$569.46 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$269.79 |