| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
2,559 |
2,559 |
$51K |
| D1120 |
Prophylaxis - child |
1,138 |
1,137 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,324 |
1,324 |
$25K |
| D0272 |
Bitewings - two radiographic images |
711 |
711 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
79 |
$12K |
| D1110 |
Prophylaxis - adult |
243 |
243 |
$10K |
| D9630 |
|
494 |
494 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
139 |
138 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
28 |
$4K |
| D1351 |
Sealant - per tooth |
87 |
25 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
19 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
210 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$695.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$375.72 |