| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,509 |
729 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,045 |
552 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,643 |
1,500 |
$42K |
| D1120 |
Prophylaxis - child |
1,613 |
1,466 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
2,007 |
1,805 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,381 |
2,121 |
$36K |
| D1110 |
Prophylaxis - adult |
918 |
824 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
327 |
179 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
726 |
532 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,145 |
992 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
325 |
$9K |
| D0330 |
Panoramic radiographic image |
238 |
225 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
944 |
804 |
$8K |
| D0272 |
Bitewings - two radiographic images |
419 |
372 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
30 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$440.25 |