| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
88 |
88 |
$13K |
| D1120 |
Prophylaxis - child |
318 |
318 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
325 |
325 |
$9K |
| D0272 |
Bitewings - two radiographic images |
276 |
276 |
$5K |
| D1206 |
Topical application of fluoride varnish |
351 |
351 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
365 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
360 |
347 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
48 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D1351 |
Sealant - per tooth |
46 |
13 |
$762.48 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$561.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$529.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$318.71 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$300.08 |
| D0603 |
|
477 |
477 |
$0.00 |