| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
346 |
346 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
245 |
$8K |
| D1351 |
Sealant - per tooth |
248 |
57 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
187 |
$4K |
| D1206 |
Topical application of fluoride varnish |
114 |
114 |
$3K |
| D0603 |
|
193 |
192 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$1K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$357.50 |
| D0602 |
|
43 |
43 |
$350.00 |
| D0273 |
|
25 |
25 |
$276.00 |