| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
671 |
671 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
467 |
467 |
$31K |
| D1310 |
|
640 |
640 |
$29K |
| D1206 |
Topical application of fluoride varnish |
976 |
976 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
186 |
186 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
186 |
$11K |
| D0603 |
|
513 |
513 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
145 |
141 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,333 |
537 |
$5K |
| D0272 |
Bitewings - two radiographic images |
371 |
371 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
40 |
$4K |
| D1351 |
Sealant - per tooth |
94 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$324.00 |
| D0602 |
|
15 |
15 |
$225.00 |