| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,240 |
1,240 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,234 |
1,234 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
792 |
792 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
350 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
82 |
$7K |
| D1351 |
Sealant - per tooth |
352 |
68 |
$7K |
| D0272 |
Bitewings - two radiographic images |
614 |
614 |
$5K |
| D0603 |
|
361 |
361 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
645 |
636 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
82 |
77 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
384 |
381 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$117.00 |
| D0602 |
|
12 |
12 |
$110.00 |