| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,295 |
1,213 |
$147K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,248 |
3,192 |
$51K |
| D1120 |
Prophylaxis - child |
1,476 |
1,461 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,073 |
1,004 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,812 |
1,783 |
$37K |
| D1110 |
Prophylaxis - adult |
765 |
745 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
262 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,105 |
1,083 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
586 |
576 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,436 |
1,383 |
$17K |
| D0272 |
Bitewings - two radiographic images |
814 |
803 |
$16K |
| D0330 |
Panoramic radiographic image |
396 |
384 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
242 |
232 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
65 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
38 |
$860.00 |
| D1354 |
|
811 |
243 |
$233.00 |
| D0270 |
|
14 |
14 |
$192.92 |
| D1330 |
|
1,954 |
1,915 |
$0.00 |
| D1310 |
|
1,811 |
1,772 |
$0.00 |
| D9215 |
|
115 |
104 |
$0.00 |
| D1353 |
|
121 |
39 |
$0.00 |
| D0191 |
|
12 |
12 |
$0.00 |