| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
724 |
679 |
$18K |
| D1120 |
Prophylaxis - child |
454 |
428 |
$17K |
| D1351 |
Sealant - per tooth |
345 |
109 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
613 |
584 |
$13K |
| D0272 |
Bitewings - two radiographic images |
201 |
186 |
$5K |
| D1110 |
Prophylaxis - adult |
54 |
51 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
70 |
64 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
15 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D9630 |
|
35 |
35 |
$560.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
26 |
$319.50 |
| D0603 |
|
118 |
111 |
$80.40 |
| D0601 |
|
29 |
28 |
$0.00 |