| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
534 |
105 |
$13K |
| D1120 |
Prophylaxis - child |
206 |
205 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
13 |
$5K |
| D1206 |
Topical application of fluoride varnish |
275 |
274 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
204 |
204 |
$5K |
| D0272 |
Bitewings - two radiographic images |
137 |
135 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
276 |
160 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
191 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
17 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$1K |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$995.22 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$768.23 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
19 |
$619.00 |
| D0601 |
|
99 |
99 |
$0.00 |
| D1330 |
|
289 |
288 |
$0.00 |
| D0603 |
|
154 |
154 |
$0.00 |
| D1999 |
|
298 |
271 |
$0.00 |