| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
207 |
207 |
$14K |
| D1351 |
Sealant - per tooth |
852 |
204 |
$9K |
| D1110 |
Prophylaxis - adult |
236 |
235 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
373 |
$5K |
| D1120 |
Prophylaxis - child |
294 |
294 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
71 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
76 |
$5K |
| D0274 |
Bitewings - four radiographic images |
279 |
278 |
$4K |
| D1206 |
Topical application of fluoride varnish |
524 |
523 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
270 |
256 |
$3K |
| D0272 |
Bitewings - two radiographic images |
203 |
203 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
256 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
228 |
214 |
$1K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$901.76 |
| D0603 |
|
420 |
419 |
$0.00 |
| D0602 |
|
109 |
109 |
$0.00 |
| D0601 |
|
133 |
133 |
$0.00 |