| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,107 |
360 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
573 |
244 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,188 |
1,121 |
$31K |
| D0145 |
Oral evaluation for a patient under three years of age |
238 |
220 |
$30K |
| D1110 |
Prophylaxis - adult |
569 |
531 |
$28K |
| D1120 |
Prophylaxis - child |
780 |
732 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
328 |
161 |
$23K |
| D0274 |
Bitewings - four radiographic images |
646 |
606 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,376 |
1,294 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,566 |
1,423 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
637 |
552 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,431 |
1,319 |
$15K |
| D0272 |
Bitewings - two radiographic images |
676 |
636 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
94 |
$3K |
| D0603 |
|
1,717 |
1,618 |
$0.00 |