| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
851 |
850 |
$37K |
| D1206 |
Topical application of fluoride varnish |
858 |
857 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
157 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
775 |
774 |
$19K |
| D0272 |
Bitewings - two radiographic images |
407 |
407 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
326 |
308 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
509 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
460 |
459 |
$3K |
| D9920 |
|
102 |
101 |
$3K |
| D0603 |
|
220 |
220 |
$2K |
| D1351 |
Sealant - per tooth |
74 |
24 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
16 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$990.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$986.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$495.00 |
| D0273 |
|
14 |
14 |
$127.14 |
| D0602 |
|
12 |
12 |
$120.00 |