| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
483 |
483 |
$13K |
| D1206 |
Topical application of fluoride varnish |
482 |
482 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
464 |
464 |
$8K |
| D0272 |
Bitewings - two radiographic images |
324 |
324 |
$5K |
| D1351 |
Sealant - per tooth |
160 |
43 |
$4K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$3K |
| D0240 |
|
170 |
169 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
34 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
89 |
79 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$2K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
52 |
$453.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
26 |
$231.84 |