| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
268 |
268 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
111 |
$11K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
91 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
41 |
$1K |
| D1351 |
Sealant - per tooth |
196 |
61 |
$895.69 |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$514.60 |
| D0120 |
Periodic oral evaluation - established patient |
300 |
300 |
$237.54 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$33.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
207 |
$27.10 |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$13.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
50 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
90 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$0.00 |