| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,172 |
670 |
$159K |
| D1110 |
Prophylaxis - adult |
2,366 |
2,255 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,418 |
3,302 |
$76K |
| D7140 |
Extraction, erupted tooth or exposed root |
723 |
218 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,933 |
2,827 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,766 |
1,685 |
$53K |
| D1120 |
Prophylaxis - child |
1,626 |
1,594 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,035 |
2,442 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,455 |
3,216 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
394 |
221 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
730 |
687 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
261 |
141 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
596 |
579 |
$17K |
| D0272 |
Bitewings - two radiographic images |
307 |
301 |
$7K |
| D0330 |
Panoramic radiographic image |
132 |
125 |
$6K |
| D9310 |
|
41 |
40 |
$930.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
25 |
$687.09 |