| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
593 |
593 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
348 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
247 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
105 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
592 |
592 |
$12K |
| D1310 |
|
252 |
252 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
253 |
240 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
81 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,449 |
594 |
$8K |
| D1351 |
Sealant - per tooth |
222 |
82 |
$8K |
| D0350 |
|
335 |
128 |
$3K |
| D0272 |
Bitewings - two radiographic images |
281 |
281 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
216 |
$3K |
| D0603 |
|
126 |
126 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$1K |
| D0602 |
|
59 |
59 |
$885.00 |