| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
580 |
580 |
$22K |
| D1351 |
Sealant - per tooth |
579 |
181 |
$19K |
| D1206 |
Topical application of fluoride varnish |
773 |
773 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
359 |
$13K |
| D9630 |
|
547 |
544 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
357 |
$9K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$6K |
| D1354 |
|
790 |
412 |
$4K |
| D1330 |
|
330 |
330 |
$3K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$3K |
| D0274 |
Bitewings - four radiographic images |
95 |
95 |
$3K |
| D0603 |
|
202 |
201 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
54 |
53 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0602 |
|
38 |
38 |
$418.00 |