| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,581 |
2,581 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,621 |
1,621 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,482 |
2,482 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
912 |
912 |
$21K |
| D1351 |
Sealant - per tooth |
289 |
192 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,241 |
1,240 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,051 |
1,051 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
130 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
198 |
173 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,030 |
1,030 |
$8K |
| D1206 |
Topical application of fluoride varnish |
141 |
141 |
$3K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$495.04 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
296 |
252 |
$0.00 |