| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
140 |
138 |
$4K |
| D1120 |
Prophylaxis - child |
101 |
98 |
$4K |
| D1351 |
Sealant - per tooth |
127 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D1206 |
Topical application of fluoride varnish |
126 |
124 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$2K |
| D0274 |
Bitewings - four radiographic images |
38 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$859.88 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$677.75 |
| D0350 |
|
121 |
24 |
$441.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
21 |
$308.70 |
| D0603 |
|
131 |
130 |
$0.00 |
| D0601 |
|
25 |
24 |
$0.00 |