| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,177 |
2,175 |
$101K |
| D1206 |
Topical application of fluoride varnish |
2,176 |
2,175 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,097 |
2,095 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
333 |
$49K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
663 |
613 |
$17K |
| D0272 |
Bitewings - two radiographic images |
629 |
628 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
500 |
$3K |
| D1351 |
Sealant - per tooth |
128 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
349 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$1K |
| D0603 |
|
98 |
98 |
$920.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$670.00 |
| D0602 |
|
14 |
14 |
$130.00 |