| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,794 |
331 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
123 |
$16K |
| D1120 |
Prophylaxis - child |
707 |
700 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
814 |
808 |
$12K |
| D1110 |
Prophylaxis - adult |
418 |
416 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
133 |
130 |
$9K |
| D0274 |
Bitewings - four radiographic images |
474 |
473 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
970 |
963 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,044 |
1,037 |
$7K |
| D0272 |
Bitewings - two radiographic images |
521 |
519 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
343 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,013 |
991 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
54 |
$4K |
| D0330 |
Panoramic radiographic image |
238 |
238 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
144 |
135 |
$2K |
| D1206 |
Topical application of fluoride varnish |
85 |
84 |
$617.40 |
| D0602 |
|
396 |
393 |
$0.00 |
| D0603 |
|
855 |
849 |
$0.00 |
| D0601 |
|
37 |
35 |
$0.00 |