| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,671 |
492 |
$69K |
| D1120 |
Prophylaxis - child |
886 |
870 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,134 |
1,115 |
$36K |
| D0330 |
Panoramic radiographic image |
357 |
356 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
436 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
647 |
639 |
$24K |
| D0272 |
Bitewings - two radiographic images |
680 |
672 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
40 |
$12K |
| D1110 |
Prophylaxis - adult |
156 |
155 |
$11K |
| D0274 |
Bitewings - four radiographic images |
166 |
165 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$898.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
12 |
$726.00 |