| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,835 |
1,835 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,153 |
2,153 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
2,131 |
2,130 |
$41K |
| D1110 |
Prophylaxis - adult |
531 |
531 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
140 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
410 |
397 |
$13K |
| D0272 |
Bitewings - two radiographic images |
628 |
627 |
$12K |
| D0274 |
Bitewings - four radiographic images |
258 |
257 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
195 |
$6K |
| D1351 |
Sealant - per tooth |
120 |
50 |
$4K |
| D9630 |
|
156 |
155 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
29 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$647.88 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$313.04 |