| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,771 |
2,771 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
2,873 |
2,873 |
$82K |
| D1206 |
Topical application of fluoride varnish |
1,138 |
1,138 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,475 |
1,475 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,629 |
1,624 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,360 |
1,360 |
$19K |
| D1351 |
Sealant - per tooth |
146 |
103 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,395 |
1,395 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
40 |
$7K |
| D1110 |
Prophylaxis - adult |
78 |
78 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$696.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
38 |
$480.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$480.00 |
| D1999 |
|
67 |
67 |
$0.00 |