| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
263 |
263 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
35 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
248 |
248 |
$8K |
| D0272 |
Bitewings - two radiographic images |
131 |
130 |
$5K |
| D1206 |
Topical application of fluoride varnish |
153 |
153 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
19 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$4K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
58 |
$3K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
19 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
67 |
$1K |