| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
436 |
421 |
$14K |
| D0272 |
Bitewings - two radiographic images |
442 |
429 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,046 |
503 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
311 |
293 |
$7K |
| D1206 |
Topical application of fluoride varnish |
483 |
464 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
613 |
566 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
31 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
83 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
34 |
$917.58 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$127.73 |
| D1330 |
|
504 |
482 |
$71.06 |
| D0603 |
|
414 |
392 |
$0.00 |
| D0601 |
|
179 |
176 |
$0.00 |