| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
338 |
38 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
27 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
119 |
$4K |
| D1120 |
Prophylaxis - child |
106 |
104 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
254 |
251 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
236 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
249 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
57 |
$2K |
| D0272 |
Bitewings - two radiographic images |
73 |
71 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$379.54 |
| D0603 |
|
308 |
304 |
$0.00 |