| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,332 |
523 |
$106K |
| D1120 |
Prophylaxis - child |
2,120 |
2,119 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
1,830 |
1,830 |
$82K |
| D1206 |
Topical application of fluoride varnish |
2,509 |
2,509 |
$81K |
| D0272 |
Bitewings - two radiographic images |
1,645 |
1,645 |
$56K |
| D9920 |
|
995 |
895 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
2,106 |
2,096 |
$32K |
| D0160 |
|
387 |
387 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,978 |
1,978 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
101 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
678 |
585 |
$17K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$1K |
| D0601 |
|
53 |
53 |
$530.00 |
| D0602 |
|
28 |
28 |
$280.00 |
| D0603 |
|
27 |
27 |
$250.00 |