| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,736 |
677 |
$87K |
| D0274 |
Bitewings - four radiographic images |
1,598 |
1,498 |
$44K |
| D1120 |
Prophylaxis - child |
1,363 |
1,284 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,823 |
1,719 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,886 |
1,775 |
$31K |
| D1110 |
Prophylaxis - adult |
680 |
638 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
113 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
108 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
125 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
75 |
51 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
76 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$580.00 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
39 |
$506.40 |
| D1999 |
|
696 |
542 |
$0.00 |