| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
190 |
190 |
$8K |
| D1206 |
Topical application of fluoride varnish |
192 |
190 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
55 |
$4K |
| D1351 |
Sealant - per tooth |
173 |
50 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
124 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
29 |
$2K |
| D0272 |
Bitewings - two radiographic images |
94 |
93 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
43 |
$875.00 |
| D0603 |
|
208 |
206 |
$555.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$377.12 |
| D1330 |
|
64 |
64 |
$0.00 |