| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,558 |
625 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
866 |
332 |
$84K |
| D0145 |
Oral evaluation for a patient under three years of age |
585 |
573 |
$80K |
| D1120 |
Prophylaxis - child |
1,371 |
1,322 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,127 |
1,422 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
833 |
793 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
930 |
901 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,662 |
1,593 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,641 |
1,540 |
$19K |
| D0272 |
Bitewings - two radiographic images |
949 |
916 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
564 |
506 |
$15K |
| D1110 |
Prophylaxis - adult |
155 |
154 |
$8K |
| D0274 |
Bitewings - four radiographic images |
136 |
133 |
$4K |
| D0330 |
Panoramic radiographic image |
171 |
165 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$890.24 |
| D0603 |
|
2,553 |
2,448 |
$0.00 |