| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
499 |
499 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
685 |
685 |
$15K |
| D1206 |
Topical application of fluoride varnish |
810 |
810 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
94 |
$10K |
| D1110 |
Prophylaxis - adult |
256 |
256 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
73 |
$7K |
| D0272 |
Bitewings - two radiographic images |
250 |
250 |
$4K |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$4K |
| D0330 |
Panoramic radiographic image |
82 |
82 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
12 |
$679.80 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$194.45 |