| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
357 |
341 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
28 |
$9K |
| D1206 |
Topical application of fluoride varnish |
433 |
410 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
267 |
257 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
140 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
80 |
$3K |
| D0272 |
Bitewings - two radiographic images |
108 |
104 |
$2K |
| D1351 |
Sealant - per tooth |
60 |
16 |
$2K |
| D1110 |
Prophylaxis - adult |
50 |
46 |
$2K |
| D0350 |
|
48 |
48 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
47 |
$601.00 |
| D9219 |
|
15 |
15 |
$598.65 |