| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
729 |
711 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
146 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
63 |
$7K |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
834 |
814 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
662 |
650 |
$1K |
| D1351 |
Sealant - per tooth |
158 |
38 |
$508.46 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
72 |
68 |
$149.28 |
| D0220 |
Intraoral - periapical first radiographic image |
871 |
849 |
$80.00 |
| D0272 |
Bitewings - two radiographic images |
559 |
547 |
$63.30 |
| D1330 |
|
917 |
897 |
$41.81 |
| D1206 |
Topical application of fluoride varnish |
956 |
927 |
$26.42 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$0.00 |