| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
446 |
445 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
111 |
111 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
470 |
469 |
$7K |
| D1351 |
Sealant - per tooth |
596 |
148 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
88 |
$6K |
| D1110 |
Prophylaxis - adult |
173 |
173 |
$5K |
| D0274 |
Bitewings - four radiographic images |
230 |
230 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
521 |
520 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
589 |
583 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
64 |
$4K |
| D0272 |
Bitewings - two radiographic images |
307 |
306 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
558 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
151 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
147 |
$2K |
| D0330 |
Panoramic radiographic image |
140 |
140 |
$1K |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$242.55 |
| D0602 |
|
97 |
96 |
$0.00 |
| D0603 |
|
609 |
609 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |