| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
303 |
44 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
17 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
100 |
$4K |
| D1120 |
Prophylaxis - child |
84 |
83 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
134 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
140 |
68 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$914.73 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
28 |
$813.30 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$769.94 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$415.62 |
| D0603 |
|
241 |
238 |
$0.00 |