| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,285 |
172 |
$30K |
| D1120 |
Prophylaxis - child |
428 |
404 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
513 |
485 |
$10K |
| D1206 |
Topical application of fluoride varnish |
603 |
567 |
$9K |
| D1110 |
Prophylaxis - adult |
134 |
123 |
$5K |
| D0272 |
Bitewings - two radiographic images |
276 |
254 |
$5K |
| D0274 |
Bitewings - four radiographic images |
172 |
160 |
$5K |
| D0330 |
Panoramic radiographic image |
118 |
106 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
126 |
114 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
166 |
162 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
17 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
43 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$727.40 |
| D1999 |
|
75 |
73 |
$0.00 |