| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
207 |
151 |
$21K |
| D1120 |
Prophylaxis - child |
464 |
463 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
611 |
610 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
177 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
442 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
98 |
$5K |
| D0274 |
Bitewings - four radiographic images |
252 |
251 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
43 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
57 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
464 |
458 |
$3K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
385 |
381 |
$2K |
| D9110 |
|
32 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$399.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$391.20 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$350.63 |