| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
521 |
521 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
129 |
124 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
322 |
$9K |
| D1206 |
Topical application of fluoride varnish |
219 |
219 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
214 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
26 |
$4K |
| D1351 |
Sealant - per tooth |
149 |
31 |
$3K |
| D0603 |
|
273 |
273 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$769.00 |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$752.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$142.00 |
| D0601 |
|
14 |
14 |
$140.00 |