| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,146 |
1,145 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
298 |
279 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
977 |
977 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,261 |
1,260 |
$18K |
| D0274 |
Bitewings - four radiographic images |
438 |
438 |
$17K |
| D1351 |
Sealant - per tooth |
362 |
145 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
68 |
$8K |
| D1110 |
Prophylaxis - adult |
127 |
127 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
49 |
$3K |
| D1353 |
|
156 |
47 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$3K |
| D0272 |
Bitewings - two radiographic images |
92 |
92 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
61 |
$950.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$715.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$342.00 |
| D9995 |
|
73 |
73 |
$0.00 |