| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
175 |
172 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
165 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
51 |
$6K |
| D0272 |
Bitewings - two radiographic images |
105 |
104 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
37 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
98 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
45 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
135 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
67 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$960.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
58 |
$922.15 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$672.00 |