| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
369 |
368 |
$14K |
| D1120 |
Prophylaxis - child |
230 |
230 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
274 |
273 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
34 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
34 |
$4K |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$4K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$4K |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
137 |
$2K |
| D1351 |
Sealant - per tooth |
62 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
96 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$395.40 |