| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
908 |
908 |
$21K |
| D1110 |
Prophylaxis - adult |
387 |
387 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
884 |
884 |
$14K |
| D1120 |
Prophylaxis - child |
400 |
400 |
$14K |
| D0272 |
Bitewings - two radiographic images |
502 |
502 |
$9K |
| D1351 |
Sealant - per tooth |
258 |
65 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
171 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
30 |
$4K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
21 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
220 |
89 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
168 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$557.08 |