| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
158 |
158 |
$7K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
71 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$2K |
| D1351 |
Sealant - per tooth |
56 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
116 |
$900.00 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$725.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
54 |
$287.00 |
| D1330 |
|
37 |
37 |
$0.00 |