| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
432 |
431 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
318 |
$21K |
| D1310 |
|
222 |
222 |
$10K |
| D1351 |
Sealant - per tooth |
246 |
78 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
423 |
419 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
146 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,781 |
443 |
$7K |
| D0350 |
|
503 |
196 |
$4K |
| D0274 |
Bitewings - four radiographic images |
165 |
164 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
52 |
$3K |
| D0603 |
|
187 |
187 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
23 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
163 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
33 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$1K |
| D9430 |
|
15 |
14 |
$480.00 |
| D0602 |
|
34 |
34 |
$465.00 |