| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
475 |
475 |
$33K |
| D1110 |
Prophylaxis - adult |
236 |
236 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$764.71 |
| D1351 |
Sealant - per tooth |
726 |
193 |
$708.22 |
| D0274 |
Bitewings - four radiographic images |
231 |
231 |
$461.02 |
| D0120 |
Periodic oral evaluation - established patient |
581 |
581 |
$104.06 |
| D0272 |
Bitewings - two radiographic images |
386 |
386 |
$31.74 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
47 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
659 |
659 |
$0.00 |