| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
652 |
651 |
$32K |
| D1206 |
Topical application of fluoride varnish |
827 |
824 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
419 |
418 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
460 |
460 |
$21K |
| D1310 |
|
321 |
321 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
615 |
606 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,446 |
546 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
42 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
27 |
18 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
66 |
63 |
$3K |
| D1351 |
Sealant - per tooth |
67 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
213 |
213 |
$2K |
| D0601 |
|
247 |
244 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
25 |
$2K |
| D0603 |
|
190 |
190 |
$1K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$660.00 |
| D0350 |
|
85 |
60 |
$573.00 |
| D1354 |
|
30 |
12 |
$240.00 |
| D0602 |
|
30 |
30 |
$158.00 |