| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,050 |
486 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
579 |
329 |
$57K |
| D1120 |
Prophylaxis - child |
1,309 |
1,304 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,508 |
1,503 |
$43K |
| D1110 |
Prophylaxis - adult |
677 |
676 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
216 |
215 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,000 |
1,994 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
422 |
421 |
$28K |
| D0274 |
Bitewings - four radiographic images |
809 |
808 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,705 |
1,680 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,628 |
1,517 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
134 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
355 |
354 |
$12K |
| D0272 |
Bitewings - two radiographic images |
508 |
505 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
47 |
$1K |
| D0603 |
|
1,605 |
1,599 |
$0.00 |
| D0602 |
|
624 |
618 |
$0.00 |
| D0601 |
|
63 |
63 |
$0.00 |
| D9986 |
|
14 |
14 |
$0.00 |