| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
246 |
240 |
$12K |
| D1206 |
Topical application of fluoride varnish |
199 |
192 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
107 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
51 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
70 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$1K |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
29 |
$947.88 |
| D0350 |
|
16 |
14 |
$907.74 |