| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
198 |
198 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
183 |
$6K |
| D0274 |
Bitewings - four radiographic images |
173 |
172 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
277 |
276 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
37 |
$5K |
| D4346 |
|
40 |
40 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
271 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
267 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |
| D1351 |
Sealant - per tooth |
46 |
17 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$626.92 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
20 |
$558.26 |