| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
407 |
407 |
$18K |
| D1206 |
Topical application of fluoride varnish |
432 |
432 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
86 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
335 |
335 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
87 |
$7K |
| D1351 |
Sealant - per tooth |
306 |
84 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
239 |
236 |
$6K |
| D0272 |
Bitewings - two radiographic images |
263 |
262 |
$3K |
| D0603 |
|
230 |
230 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
339 |
$2K |
| D0601 |
|
118 |
118 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
315 |
$1K |
| D1353 |
|
105 |
33 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$535.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$312.00 |