| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,663 |
1,274 |
$294K |
| D1120 |
Prophylaxis - child |
5,353 |
4,667 |
$203K |
| D0120 |
Periodic oral evaluation - established patient |
8,047 |
7,063 |
$200K |
| D1110 |
Prophylaxis - adult |
3,678 |
3,303 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,595 |
1,097 |
$187K |
| D1206 |
Topical application of fluoride varnish |
8,478 |
7,419 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,272 |
944 |
$121K |
| D0330 |
Panoramic radiographic image |
1,368 |
1,234 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,104 |
562 |
$82K |
| D0272 |
Bitewings - two radiographic images |
2,662 |
2,297 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,439 |
1,310 |
$54K |
| D1320 |
|
1,804 |
1,506 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
969 |
926 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
789 |
734 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
754 |
720 |
$12K |
| D2331 |
|
90 |
66 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
32 |
$737.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
12 |
$704.00 |
| D1999 |
|
848 |
415 |
$0.00 |