| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
823 |
113 |
$20K |
| D1120 |
Prophylaxis - child |
666 |
633 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
720 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,537 |
801 |
$13K |
| D0272 |
Bitewings - two radiographic images |
436 |
412 |
$9K |
| D0274 |
Bitewings - four radiographic images |
320 |
300 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
888 |
832 |
$8K |
| D1110 |
Prophylaxis - adult |
175 |
167 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
502 |
471 |
$6K |
| D1206 |
Topical application of fluoride varnish |
362 |
355 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
103 |
98 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
29 |
$858.29 |
| D0330 |
Panoramic radiographic image |
32 |
29 |
$806.07 |
| D0603 |
|
933 |
905 |
$0.00 |