| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
620 |
341 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
541 |
309 |
$8K |
| D1206 |
Topical application of fluoride varnish |
279 |
190 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
34 |
$4K |
| D0330 |
Panoramic radiographic image |
94 |
60 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
250 |
147 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
60 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
113 |
$2K |
| D0274 |
Bitewings - four radiographic images |
121 |
65 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
129 |
$1K |
| D1351 |
Sealant - per tooth |
49 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
135 |
64 |
$986.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
128 |
74 |
$932.24 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$601.90 |
| D1999 |
|
241 |
227 |
$0.00 |