| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,029 |
1,027 |
$42K |
| D0330 |
Panoramic radiographic image |
243 |
243 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
499 |
499 |
$15K |
| D1110 |
Prophylaxis - adult |
216 |
214 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
98 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
28 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
12 |
$312.45 |
| D0120 |
Periodic oral evaluation - established patient |
699 |
696 |
$196.28 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
361 |
326 |
$96.54 |
| D0272 |
Bitewings - two radiographic images |
812 |
812 |
$15.87 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,203 |
1,200 |
$13.55 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
39 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
164 |
163 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
138 |
138 |
$0.00 |