| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,973 |
1,960 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,733 |
2,714 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,184 |
2,170 |
$38K |
| D1110 |
Prophylaxis - adult |
306 |
306 |
$12K |
| D0272 |
Bitewings - two radiographic images |
402 |
402 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
115 |
91 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
136 |
50 |
$3K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$650.62 |