| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
916 |
913 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,139 |
1,136 |
$29K |
| D1351 |
Sealant - per tooth |
678 |
128 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
354 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
541 |
541 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
54 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
263 |
216 |
$5K |
| D0272 |
Bitewings - two radiographic images |
266 |
266 |
$4K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$3K |
| D1330 |
|
248 |
248 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$517.60 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$504.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$402.30 |