| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
561 |
560 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
398 |
398 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
82 |
$10K |
| D1206 |
Topical application of fluoride varnish |
632 |
605 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
178 |
165 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$4K |
| D0272 |
Bitewings - two radiographic images |
211 |
211 |
$4K |
| D0603 |
|
485 |
484 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
204 |
$3K |
| D1351 |
Sealant - per tooth |
77 |
28 |
$3K |
| D1354 |
|
327 |
105 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
82 |
$837.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$594.00 |
| D0602 |
|
78 |
78 |
$550.00 |
| D1330 |
|
610 |
609 |
$100.00 |