| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
719 |
718 |
$33K |
| D1110 |
Prophylaxis - adult |
137 |
136 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
30 |
$6K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
207 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
29 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
519 |
517 |
$1K |
| D1351 |
Sealant - per tooth |
346 |
71 |
$676.65 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$616.49 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
270 |
237 |
$291.49 |
| D0272 |
Bitewings - two radiographic images |
505 |
505 |
$246.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
621 |
621 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
77 |
76 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
297 |
296 |
$-98.29 |