| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
174 |
172 |
$6K |
| D1206 |
Topical application of fluoride varnish |
236 |
234 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
183 |
183 |
$4K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
40 |
$1K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
23 |
$717.80 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$585.91 |
| D0272 |
Bitewings - two radiographic images |
24 |
22 |
$380.94 |