| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
974 |
974 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
714 |
$47K |
| D1351 |
Sealant - per tooth |
759 |
186 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
329 |
164 |
$23K |
| D1310 |
|
458 |
458 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
284 |
284 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
806 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,447 |
532 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
175 |
175 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
127 |
127 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
59 |
$7K |
| D0603 |
|
457 |
457 |
$7K |
| D1206 |
Topical application of fluoride varnish |
219 |
219 |
$6K |
| D9430 |
|
133 |
125 |
$4K |
| D0274 |
Bitewings - four radiographic images |
205 |
205 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
314 |
$4K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
78 |
71 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
15 |
$2K |
| D0350 |
|
128 |
65 |
$1K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$667.00 |