| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,668 |
451 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,940 |
1,929 |
$39K |
| D1120 |
Prophylaxis - child |
1,096 |
1,085 |
$32K |
| D1110 |
Prophylaxis - adult |
845 |
841 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
297 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,209 |
1,201 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
475 |
431 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
170 |
$12K |
| D0274 |
Bitewings - four radiographic images |
319 |
319 |
$9K |
| D1330 |
|
808 |
797 |
$7K |
| D1310 |
|
737 |
728 |
$6K |
| D0272 |
Bitewings - two radiographic images |
404 |
399 |
$6K |
| D1206 |
Topical application of fluoride varnish |
339 |
336 |
$6K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
170 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D0603 |
|
30 |
30 |
$300.00 |
| D0602 |
|
12 |
12 |
$120.00 |