| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
526 |
485 |
$22K |
| D1206 |
Topical application of fluoride varnish |
547 |
503 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
271 |
$8K |
| D1351 |
Sealant - per tooth |
392 |
63 |
$5K |
| D0330 |
Panoramic radiographic image |
172 |
166 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
882 |
364 |
$4K |
| D0274 |
Bitewings - four radiographic images |
219 |
205 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
32 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
273 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
104 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
15 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
79 |
66 |
$977.32 |
| D0272 |
Bitewings - two radiographic images |
25 |
24 |
$403.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
24 |
$204.80 |
| D0470 |
|
15 |
14 |
$0.00 |
| D9310 |
|
31 |
30 |
$0.00 |
| D0350 |
|
16 |
15 |
$0.00 |
| D0340 |
|
31 |
30 |
$0.00 |