| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9630 |
|
115 |
102 |
$4K |
| D1206 |
Topical application of fluoride varnish |
118 |
115 |
$3K |
| D1351 |
Sealant - per tooth |
86 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
148 |
$1K |
| D1120 |
Prophylaxis - child |
52 |
51 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
105 |
$631.98 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
16 |
$504.00 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
17 |
$326.25 |
| D1330 |
|
35 |
34 |
$0.00 |