| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
476 |
476 |
$17K |
| D1120 |
Prophylaxis - child |
465 |
465 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
632 |
632 |
$12K |
| D1351 |
Sealant - per tooth |
446 |
112 |
$11K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
736 |
735 |
$9K |
| D1110 |
Prophylaxis - adult |
170 |
170 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
776 |
662 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
66 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
25 |
$5K |
| D0272 |
Bitewings - two radiographic images |
242 |
242 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
363 |
227 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
16 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
145 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$1K |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$461.78 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$426.95 |
| D0603 |
|
60 |
58 |
$0.00 |