| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
272 |
270 |
$37K |
| D1351 |
Sealant - per tooth |
787 |
130 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
395 |
$13K |
| D1120 |
Prophylaxis - child |
352 |
340 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
426 |
$6K |
| D0272 |
Bitewings - two radiographic images |
277 |
267 |
$5K |
| D1206 |
Topical application of fluoride varnish |
417 |
403 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
457 |
436 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
26 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
47 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$549.18 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$415.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$404.57 |
| D0603 |
|
799 |
775 |
$0.00 |