| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
42 |
29 |
$6K |
| D1120 |
Prophylaxis - child |
201 |
186 |
$5K |
| D1206 |
Topical application of fluoride varnish |
215 |
199 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
113 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
71 |
50 |
$2K |
| D0274 |
Bitewings - four radiographic images |
35 |
32 |
$1K |
| D1310 |
|
204 |
190 |
$940.00 |
| D1330 |
|
204 |
190 |
$940.00 |
| D0601 |
|
91 |
85 |
$834.00 |
| D0603 |
|
67 |
62 |
$580.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
40 |
$427.88 |
| D0240 |
|
12 |
12 |
$316.80 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
13 |
$312.00 |