| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
269 |
269 |
$12K |
| D1206 |
Topical application of fluoride varnish |
305 |
305 |
$10K |
| D1351 |
Sealant - per tooth |
249 |
46 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
134 |
134 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
28 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
90 |
87 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0603 |
|
97 |
97 |
$970.00 |
| D0220 |
Intraoral - periapical first radiographic image |
165 |
165 |
$825.00 |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$700.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
143 |
$489.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$144.00 |
| D0601 |
|
12 |
12 |
$120.00 |