| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
499 |
497 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
372 |
$25K |
| D1310 |
|
321 |
319 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
323 |
323 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
58 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
152 |
132 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,260 |
439 |
$5K |
| D0272 |
Bitewings - two radiographic images |
247 |
246 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
47 |
47 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
47 |
$2K |
| D1206 |
Topical application of fluoride varnish |
109 |
107 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
18 |
$2K |
| D0601 |
|
136 |
136 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$864.00 |
| D0602 |
|
20 |
20 |
$285.00 |
| D0603 |
|
13 |
13 |
$150.00 |