| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
318 |
73 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
38 |
$5K |
| D1206 |
Topical application of fluoride varnish |
251 |
231 |
$4K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
29 |
$3K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$2K |
| D0240 |
|
112 |
62 |
$1K |
| D0272 |
Bitewings - two radiographic images |
77 |
77 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
60 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
31 |
$968.55 |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$937.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$725.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
23 |
$548.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$533.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
45 |
$492.00 |