| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,258 |
256 |
$17K |
| D1120 |
Prophylaxis - child |
569 |
565 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
603 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
191 |
108 |
$7K |
| D1110 |
Prophylaxis - adult |
260 |
259 |
$7K |
| D0274 |
Bitewings - four radiographic images |
335 |
335 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
58 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
682 |
678 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
247 |
$4K |
| D0272 |
Bitewings - two radiographic images |
339 |
336 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
477 |
472 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
427 |
421 |
$2K |
| D0330 |
Panoramic radiographic image |
177 |
177 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$1K |
| D1206 |
Topical application of fluoride varnish |
104 |
103 |
$757.05 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
29 |
$406.80 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$131.46 |
| D0602 |
|
126 |
126 |
$0.00 |
| D0603 |
|
699 |
694 |
$0.00 |
| D0601 |
|
39 |
39 |
$0.00 |