| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
734 |
734 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
868 |
867 |
$22K |
| D1206 |
Topical application of fluoride varnish |
943 |
942 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
199 |
195 |
$11K |
| D1110 |
Prophylaxis - adult |
161 |
160 |
$7K |
| D0272 |
Bitewings - two radiographic images |
316 |
316 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
43 |
$4K |
| D0274 |
Bitewings - four radiographic images |
72 |
71 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$937.50 |
| D1351 |
Sealant - per tooth |
29 |
12 |
$906.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$305.00 |
| D0240 |
|
29 |
13 |
$285.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$130.00 |