| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
586 |
110 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
406 |
$11K |
| D1120 |
Prophylaxis - child |
289 |
273 |
$9K |
| D0274 |
Bitewings - four radiographic images |
302 |
264 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
558 |
535 |
$7K |
| D1110 |
Prophylaxis - adult |
150 |
143 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
417 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
436 |
400 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
92 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$847.68 |
| D0272 |
Bitewings - two radiographic images |
15 |
14 |
$303.94 |
| D0603 |
|
569 |
539 |
$0.00 |
| D0602 |
|
62 |
62 |
$0.00 |