| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,378 |
1,283 |
$28K |
| D1120 |
Prophylaxis - child |
923 |
923 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
200 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
848 |
848 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
251 |
180 |
$14K |
| D1351 |
Sealant - per tooth |
458 |
79 |
$11K |
| D1110 |
Prophylaxis - adult |
311 |
310 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$4K |
| D0272 |
Bitewings - two radiographic images |
319 |
319 |
$4K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
116 |
$4K |
| D0274 |
Bitewings - four radiographic images |
201 |
201 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$270.00 |