| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
672 |
670 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
760 |
758 |
$19K |
| D1206 |
Topical application of fluoride varnish |
803 |
801 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
215 |
213 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
67 |
$6K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$5K |
| D0272 |
Bitewings - two radiographic images |
221 |
221 |
$4K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
27 |
$2K |
| D0240 |
|
101 |
38 |
$982.00 |
| D1330 |
|
79 |
79 |
$790.00 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$780.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$325.00 |