| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,528 |
400 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,440 |
1,414 |
$30K |
| D1120 |
Prophylaxis - child |
903 |
893 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,499 |
1,474 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
392 |
353 |
$18K |
| D1110 |
Prophylaxis - adult |
480 |
464 |
$17K |
| D0274 |
Bitewings - four radiographic images |
458 |
443 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
107 |
$12K |
| D0272 |
Bitewings - two radiographic images |
694 |
686 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
500 |
443 |
$4K |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
134 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$775.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$574.20 |
| D1999 |
|
836 |
762 |
$0.00 |