| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
141 |
122 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
52 |
$8K |
| D1206 |
Topical application of fluoride varnish |
415 |
405 |
$8K |
| D1120 |
Prophylaxis - child |
260 |
259 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
227 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
29 |
$4K |
| D0603 |
|
346 |
344 |
$3K |
| D0240 |
|
108 |
106 |
$3K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
78 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
120 |
$2K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$2K |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$2K |
| D1330 |
|
345 |
344 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
113 |
$1K |
| D1310 |
|
188 |
187 |
$895.87 |