| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
475 |
475 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
152 |
$10K |
| D1206 |
Topical application of fluoride varnish |
455 |
455 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,869 |
411 |
$7K |
| D1310 |
|
376 |
375 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
114 |
104 |
$5K |
| D1351 |
Sealant - per tooth |
46 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
120 |
120 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
84 |
$960.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |
| D0602 |
|
12 |
12 |
$172.50 |
| D1330 |
|
246 |
246 |
$0.00 |