| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,082 |
1,082 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,153 |
1,153 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
841 |
841 |
$21K |
| D0272 |
Bitewings - two radiographic images |
371 |
371 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
98 |
84 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
71 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
87 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$220.00 |