| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
624 |
622 |
$27K |
| D1351 |
Sealant - per tooth |
1,335 |
300 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
158 |
$21K |
| D1206 |
Topical application of fluoride varnish |
668 |
665 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
578 |
577 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
68 |
$7K |
| D1353 |
|
797 |
176 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
276 |
273 |
$7K |
| D0603 |
|
379 |
379 |
$3K |
| D0272 |
Bitewings - two radiographic images |
297 |
296 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
509 |
$2K |
| D0274 |
Bitewings - four radiographic images |
162 |
162 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
476 |
475 |
$1K |
| D0601 |
|
96 |
96 |
$840.00 |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$630.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$540.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$275.00 |
| D0602 |
|
12 |
12 |
$120.00 |