| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,055 |
1,055 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,041 |
1,041 |
$32K |
| D1206 |
Topical application of fluoride varnish |
480 |
480 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
462 |
462 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
41 |
$7K |
| D0272 |
Bitewings - two radiographic images |
304 |
304 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
59 |
59 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0240 |
|
44 |
22 |
$832.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$789.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$480.00 |