| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,717 |
650 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
825 |
348 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,517 |
1,516 |
$33K |
| D1110 |
Prophylaxis - adult |
842 |
842 |
$32K |
| D1120 |
Prophylaxis - child |
1,015 |
1,014 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,097 |
1,096 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,257 |
1,257 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
406 |
406 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
395 |
395 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
202 |
147 |
$9K |
| D1206 |
Topical application of fluoride varnish |
407 |
407 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
226 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
160 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$955.50 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$256.00 |
| D1999 |
|
18 |
15 |
$0.00 |