| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
315 |
308 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
178 |
163 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
160 |
$7K |
| D1206 |
Topical application of fluoride varnish |
435 |
419 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
28 |
$6K |
| D1351 |
Sealant - per tooth |
237 |
46 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
144 |
$4K |
| D0330 |
Panoramic radiographic image |
30 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
91 |
84 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$265.20 |