| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
857 |
853 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
143 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,033 |
1,030 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
820 |
819 |
$26K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$5K |
| D0272 |
Bitewings - two radiographic images |
278 |
278 |
$5K |
| D1351 |
Sealant - per tooth |
144 |
29 |
$4K |
| D0274 |
Bitewings - four radiographic images |
176 |
176 |
$4K |
| D9248 |
|
13 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
38 |
$767.91 |