| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
512 |
512 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
597 |
596 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
323 |
323 |
$5K |
| D0272 |
Bitewings - two radiographic images |
197 |
196 |
$4K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$3K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
69 |
68 |
$3K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
52 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
79 |
$793.80 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$396.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
41 |
$304.20 |