| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,570 |
692 |
$71K |
| D1110 |
Prophylaxis - adult |
994 |
994 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,827 |
1,826 |
$53K |
| D1120 |
Prophylaxis - child |
1,257 |
1,256 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,472 |
2,471 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,046 |
1,045 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
321 |
207 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
870 |
758 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
138 |
138 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
185 |
185 |
$13K |
| D0272 |
Bitewings - two radiographic images |
483 |
483 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
65 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
299 |
$11K |
| D0603 |
|
2,410 |
2,406 |
$0.00 |
| D0602 |
|
43 |
43 |
$0.00 |
| D0601 |
|
25 |
25 |
$0.00 |