| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
869 |
869 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,099 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,052 |
1,052 |
$14K |
| D1110 |
Prophylaxis - adult |
84 |
84 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
28 |
$4K |
| D1351 |
Sealant - per tooth |
56 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
131 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$915.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
31 |
$572.67 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$254.01 |