| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
701 |
179 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
517 |
513 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
90 |
90 |
$12K |
| D1120 |
Prophylaxis - child |
350 |
347 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
65 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
79 |
$9K |
| D1110 |
Prophylaxis - adult |
167 |
165 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
543 |
537 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
544 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
577 |
565 |
$7K |
| D0272 |
Bitewings - two radiographic images |
289 |
287 |
$6K |
| D0274 |
Bitewings - four radiographic images |
172 |
170 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
116 |
111 |
$3K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$314.24 |
| D0603 |
|
701 |
695 |
$0.00 |