| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,551 |
3,550 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
4,948 |
4,948 |
$133K |
| D1110 |
Prophylaxis - adult |
1,113 |
1,113 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,536 |
3,536 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
284 |
186 |
$22K |
| D1206 |
Topical application of fluoride varnish |
685 |
684 |
$19K |
| D1351 |
Sealant - per tooth |
451 |
154 |
$17K |
| D0272 |
Bitewings - two radiographic images |
849 |
848 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
140 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
63 |
$5K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
57 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
16 |
$234.65 |
| D0350 |
|
12 |
12 |
$26.60 |
| D1330 |
|
20 |
20 |
$0.00 |