| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
857 |
184 |
$17K |
| D1120 |
Prophylaxis - child |
327 |
327 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
94 |
$12K |
| D1206 |
Topical application of fluoride varnish |
366 |
366 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
325 |
325 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
64 |
$5K |
| D1353 |
|
555 |
121 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
151 |
$4K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$1K |
| D0603 |
|
199 |
199 |
$1K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
202 |
$924.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$495.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
169 |
$486.00 |
| D0601 |
|
70 |
69 |
$410.00 |