| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,801 |
698 |
$158K |
| D1120 |
Prophylaxis - child |
1,585 |
1,274 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,832 |
1,462 |
$34K |
| D0274 |
Bitewings - four radiographic images |
484 |
354 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
498 |
428 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
225 |
$9K |
| D0272 |
Bitewings - two radiographic images |
209 |
165 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
12 |
$4K |
| D0190 |
|
603 |
428 |
$3K |
| D0240 |
|
44 |
19 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$547.50 |
| D1999 |
|
117 |
92 |
$0.00 |