| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,926 |
1,217 |
$150K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,690 |
782 |
$141K |
| D1120 |
Prophylaxis - child |
5,006 |
3,827 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
4,969 |
3,793 |
$89K |
| D0330 |
Panoramic radiographic image |
1,801 |
1,478 |
$78K |
| D1206 |
Topical application of fluoride varnish |
3,354 |
2,685 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
610 |
286 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,019 |
712 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,161 |
862 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
175 |
79 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
236 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,721 |
1,249 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
845 |
529 |
$7K |
| D0272 |
Bitewings - two radiographic images |
215 |
138 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$488.76 |
| D1999 |
|
47 |
30 |
$0.00 |