| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,022 |
306 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,037 |
1,009 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
153 |
$19K |
| D1120 |
Prophylaxis - child |
613 |
596 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
327 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
115 |
$11K |
| D0330 |
Panoramic radiographic image |
148 |
142 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
437 |
436 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
129 |
$6K |
| D0272 |
Bitewings - two radiographic images |
351 |
351 |
$6K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
313 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
89 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
42 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
18 |
$757.00 |
| D0240 |
|
91 |
70 |
$487.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$77.00 |