| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
830 |
133 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
73 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
268 |
$13K |
| D1206 |
Topical application of fluoride varnish |
500 |
498 |
$12K |
| D1120 |
Prophylaxis - child |
286 |
283 |
$11K |
| D0330 |
Panoramic radiographic image |
86 |
86 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
174 |
160 |
$3K |
| D0272 |
Bitewings - two radiographic images |
150 |
148 |
$2K |
| D2940 |
|
39 |
13 |
$2K |
| D1330 |
|
252 |
250 |
$1K |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$930.56 |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
88 |
$720.08 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$648.00 |