| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,515 |
943 |
$138K |
| D1120 |
Prophylaxis - child |
2,545 |
2,538 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,329 |
3,317 |
$95K |
| D4341 |
|
580 |
243 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,932 |
1,925 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
642 |
491 |
$39K |
| D1110 |
Prophylaxis - adult |
697 |
695 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,720 |
1,708 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
782 |
776 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
486 |
363 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
63 |
53 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,539 |
2,513 |
$17K |
| D1206 |
Topical application of fluoride varnish |
575 |
575 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,505 |
2,186 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
408 |
401 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
92 |
90 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
58 |
$5K |
| D0272 |
Bitewings - two radiographic images |
379 |
378 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
41 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
100 |
$3K |
| D4910 |
|
12 |
12 |
$737.00 |
| D0270 |
|
51 |
50 |
$280.00 |