| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,156 |
1,124 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,358 |
1,319 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
740 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
431 |
$7K |
| D0272 |
Bitewings - two radiographic images |
563 |
546 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
853 |
825 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
772 |
730 |
$3K |
| D0330 |
Panoramic radiographic image |
176 |
174 |
$2K |
| D1351 |
Sealant - per tooth |
82 |
26 |
$882.09 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
25 |
$792.83 |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$437.57 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
58 |
$401.33 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$126.00 |
| D1330 |
|
452 |
426 |
$0.00 |