| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
629 |
141 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
341 |
318 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
38 |
$4K |
| D1120 |
Prophylaxis - child |
213 |
204 |
$3K |
| D1110 |
Prophylaxis - adult |
118 |
116 |
$3K |
| D0274 |
Bitewings - four radiographic images |
181 |
176 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
342 |
327 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
412 |
377 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
390 |
354 |
$2K |
| D0272 |
Bitewings - two radiographic images |
149 |
142 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
44 |
$596.64 |
| D0603 |
|
330 |
315 |
$0.00 |
| D0602 |
|
45 |
45 |
$0.00 |