| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,405 |
445 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,442 |
1,431 |
$41K |
| D1110 |
Prophylaxis - adult |
979 |
967 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
336 |
215 |
$27K |
| D1120 |
Prophylaxis - child |
801 |
797 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,751 |
1,734 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
678 |
619 |
$13K |
| D0330 |
Panoramic radiographic image |
247 |
239 |
$10K |
| D0274 |
Bitewings - four radiographic images |
531 |
525 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
161 |
$9K |
| D0272 |
Bitewings - two radiographic images |
300 |
298 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D1330 |
|
71 |
71 |
$910.00 |