| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,026 |
456 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,911 |
2,773 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,295 |
2,171 |
$48K |
| D1120 |
Prophylaxis - child |
1,937 |
1,842 |
$47K |
| D1110 |
Prophylaxis - adult |
1,213 |
1,168 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
436 |
305 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
748 |
651 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
442 |
297 |
$24K |
| D0603 |
|
1,668 |
1,596 |
$16K |
| D0274 |
Bitewings - four radiographic images |
471 |
448 |
$14K |
| D0272 |
Bitewings - two radiographic images |
715 |
685 |
$12K |
| D0330 |
Panoramic radiographic image |
290 |
276 |
$10K |
| D1330 |
|
1,711 |
1,640 |
$8K |
| D1310 |
|
1,706 |
1,636 |
$8K |
| D1354 |
|
753 |
199 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
809 |
673 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
31 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
501 |
425 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
176 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
118 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |
| D3120 |
|
65 |
47 |
$64.80 |
| D9215 |
|
221 |
186 |
$0.00 |