| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
416 |
107 |
$6K |
| D1120 |
Prophylaxis - child |
238 |
237 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
267 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
42 |
$3K |
| D1110 |
Prophylaxis - adult |
115 |
114 |
$3K |
| D0274 |
Bitewings - four radiographic images |
147 |
146 |
$2K |
| D0272 |
Bitewings - two radiographic images |
173 |
172 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
325 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
259 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
314 |
290 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
120 |
116 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
28 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$994.56 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$900.66 |
| D1206 |
Topical application of fluoride varnish |
57 |
57 |
$404.25 |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$323.86 |
| D0603 |
|
340 |
338 |
$0.00 |
| D0602 |
|
33 |
32 |
$0.00 |