| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
273 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
201 |
196 |
$3K |
| D1206 |
Topical application of fluoride varnish |
308 |
302 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
76 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
263 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
281 |
206 |
$1K |
| D0272 |
Bitewings - two radiographic images |
114 |
111 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$423.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$176.60 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
12 |
$81.33 |
| D0350 |
|
50 |
49 |
$0.00 |
| D0602 |
|
452 |
438 |
$0.00 |