| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,202 |
289 |
$51K |
| D0274 |
Bitewings - four radiographic images |
718 |
687 |
$14K |
| D1120 |
Prophylaxis - child |
515 |
490 |
$13K |
| D0330 |
Panoramic radiographic image |
228 |
222 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
629 |
600 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
516 |
491 |
$10K |
| D1110 |
Prophylaxis - adult |
253 |
247 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
59 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
137 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
24 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
136 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$248.00 |