| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
818 |
802 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
682 |
$15K |
| D1120 |
Prophylaxis - child |
547 |
546 |
$13K |
| D1351 |
Sealant - per tooth |
181 |
43 |
$4K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
26 |
$3K |
| D1330 |
|
644 |
643 |
$3K |
| D0602 |
|
296 |
296 |
$3K |
| D0603 |
|
290 |
290 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
86 |
80 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D1310 |
|
55 |
54 |
$265.00 |