| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,264 |
1,255 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
985 |
976 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,034 |
1,023 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
256 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
72 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
324 |
324 |
$5K |
| D0272 |
Bitewings - two radiographic images |
264 |
256 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
89 |
76 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
13 |
$1K |
| D0240 |
|
16 |
12 |
$288.00 |