| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
960 |
160 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
67 |
$6K |
| D1120 |
Prophylaxis - child |
290 |
236 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
263 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
51 |
$3K |
| D0274 |
Bitewings - four radiographic images |
181 |
145 |
$2K |
| D1110 |
Prophylaxis - adult |
124 |
95 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
312 |
$2K |
| D0272 |
Bitewings - two radiographic images |
181 |
148 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
164 |
126 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
319 |
272 |
$1K |
| D1206 |
Topical application of fluoride varnish |
281 |
204 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
84 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
160 |
155 |
$1K |
| D0330 |
Panoramic radiographic image |
81 |
63 |
$556.78 |
| D0603 |
|
415 |
343 |
$0.00 |