| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
624 |
624 |
$23K |
| D1206 |
Topical application of fluoride varnish |
599 |
599 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
341 |
340 |
$9K |
| D0603 |
|
501 |
498 |
$4K |
| D1351 |
Sealant - per tooth |
124 |
45 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
139 |
91 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
30 |
$3K |
| D0272 |
Bitewings - two radiographic images |
147 |
146 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
144 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
24 |
$517.05 |
| D0240 |
|
24 |
12 |
$384.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$247.00 |
| D1310 |
|
93 |
93 |
$0.00 |
| D1330 |
|
93 |
93 |
$0.00 |