| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
802 |
801 |
$36K |
| D8670 |
Periodic orthodontic treatment visit |
370 |
364 |
$27K |
| D1110 |
Prophylaxis - adult |
165 |
164 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
291 |
291 |
$9K |
| D0330 |
Panoramic radiographic image |
99 |
98 |
$8K |
| D1351 |
Sealant - per tooth |
568 |
100 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
28 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
531 |
$152.07 |
| D0274 |
Bitewings - four radiographic images |
129 |
128 |
$84.01 |
| D1208 |
Topical application of fluoride, excluding varnish |
705 |
704 |
$79.32 |
| D0272 |
Bitewings - two radiographic images |
528 |
527 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
166 |
148 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
339 |
338 |
$-77.96 |