| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
605 |
605 |
$27K |
| D1206 |
Topical application of fluoride varnish |
661 |
661 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
569 |
569 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
76 |
$9K |
| D1351 |
Sealant - per tooth |
300 |
56 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
204 |
191 |
$5K |
| D0602 |
|
258 |
258 |
$3K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
232 |
232 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
185 |
$582.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$325.00 |
| D0603 |
|
28 |
28 |
$280.00 |