| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
491 |
89 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
60 |
$8K |
| D1120 |
Prophylaxis - child |
240 |
233 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
270 |
251 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
557 |
483 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
518 |
435 |
$4K |
| D0272 |
Bitewings - two radiographic images |
201 |
196 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
257 |
251 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
30 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
110 |
101 |
$3K |
| D1206 |
Topical application of fluoride varnish |
210 |
166 |
$2K |
| D1110 |
Prophylaxis - adult |
68 |
49 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
58 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
85 |
61 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
12 |
$231.90 |
| D1330 |
|
39 |
27 |
$0.00 |
| D0603 |
|
630 |
599 |
$0.00 |
| D0431 |
|
19 |
15 |
$0.00 |