| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,743 |
237 |
$39K |
| D1120 |
Prophylaxis - child |
561 |
555 |
$25K |
| D1206 |
Topical application of fluoride varnish |
627 |
618 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
637 |
605 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
361 |
354 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
302 |
135 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
475 |
469 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
966 |
949 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,743 |
686 |
$10K |
| D0274 |
Bitewings - four radiographic images |
249 |
247 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
224 |
$6K |
| D1353 |
|
289 |
47 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
31 |
$3K |
| D7311 |
|
115 |
56 |
$1K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
52 |
49 |
$958.88 |
| D0270 |
|
52 |
52 |
$616.05 |
| D0999 |
Unspecified diagnostic procedure, by report |
17 |
17 |
$510.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
31 |
31 |
$480.00 |
| D5899 |
|
35 |
13 |
$348.50 |
| D1999 |
|
442 |
395 |
$285.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$143.36 |
| D4346 |
|
16 |
13 |
$0.00 |