| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
216 |
216 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
256 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
43 |
$3K |
| D1206 |
Topical application of fluoride varnish |
333 |
333 |
$2K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$2K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$2K |
| D0272 |
Bitewings - two radiographic images |
162 |
162 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
124 |
29 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
92 |
86 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$865.34 |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
121 |
$753.29 |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$343.94 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
57 |
$339.79 |
| D0603 |
|
282 |
282 |
$0.00 |
| D0602 |
|
82 |
82 |
$0.00 |