| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
568 |
568 |
$15K |
| D1206 |
Topical application of fluoride varnish |
594 |
594 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
87 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
370 |
370 |
$7K |
| D0272 |
Bitewings - two radiographic images |
361 |
361 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
260 |
$6K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
129 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
41 |
$3K |
| D1351 |
Sealant - per tooth |
85 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
136 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
59 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$634.81 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
12 |
$230.96 |