| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
937 |
338 |
$22K |
| D1120 |
Prophylaxis - child |
671 |
663 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
849 |
840 |
$17K |
| D1206 |
Topical application of fluoride varnish |
934 |
925 |
$15K |
| D1110 |
Prophylaxis - adult |
260 |
259 |
$10K |
| D0272 |
Bitewings - two radiographic images |
537 |
529 |
$10K |
| D0274 |
Bitewings - four radiographic images |
261 |
260 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
72 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
125 |
111 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |