| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
315 |
193 |
$25K |
| D1120 |
Prophylaxis - child |
564 |
563 |
$24K |
| D1206 |
Topical application of fluoride varnish |
553 |
553 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
468 |
468 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
139 |
138 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
86 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
363 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
321 |
$2K |
| D0272 |
Bitewings - two radiographic images |
134 |
134 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
15 |
$618.80 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$191.20 |