| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
342 |
342 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
364 |
$9K |
| D1206 |
Topical application of fluoride varnish |
415 |
415 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
85 |
82 |
$5K |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$4K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$2K |
| D0272 |
Bitewings - two radiographic images |
98 |
97 |
$2K |
| D0240 |
|
111 |
67 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
77 |
$743.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$573.25 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$301.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$226.00 |