| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
259 |
255 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
168 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
38 |
$5K |
| D1351 |
Sealant - per tooth |
159 |
44 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
252 |
$4K |
| D0272 |
Bitewings - two radiographic images |
83 |
82 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
132 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
114 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
45 |
44 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
35 |
$1K |
| D0603 |
|
472 |
463 |
$0.00 |