| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,396 |
316 |
$55K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
430 |
146 |
$55K |
| D1110 |
Prophylaxis - adult |
1,290 |
1,268 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
248 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
726 |
712 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,716 |
1,684 |
$35K |
| D1120 |
Prophylaxis - child |
1,055 |
1,032 |
$31K |
| D0274 |
Bitewings - four radiographic images |
952 |
930 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,428 |
1,397 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
752 |
734 |
$21K |
| D0272 |
Bitewings - two radiographic images |
650 |
638 |
$13K |
| D0240 |
|
285 |
283 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
65 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
75 |
$912.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
41 |
$840.00 |