| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,528 |
297 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
722 |
$20K |
| D1120 |
Prophylaxis - child |
427 |
420 |
$15K |
| D1110 |
Prophylaxis - adult |
258 |
251 |
$13K |
| D0272 |
Bitewings - two radiographic images |
497 |
489 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
749 |
735 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
74 |
73 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
860 |
838 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
819 |
797 |
$9K |
| D0274 |
Bitewings - four radiographic images |
183 |
176 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
34 |
$784.11 |
| D0603 |
|
781 |
765 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |