| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
143 |
141 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
28 |
$4K |
| D1351 |
Sealant - per tooth |
140 |
33 |
$2K |
| D1120 |
Prophylaxis - child |
60 |
59 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$806.35 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
31 |
$222.96 |
| D1330 |
|
124 |
123 |
$212.34 |
| D1206 |
Topical application of fluoride varnish |
140 |
138 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$0.00 |
| D1999 |
|
13 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |