| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,395 |
325 |
$51K |
| D1120 |
Prophylaxis - child |
730 |
706 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
581 |
539 |
$30K |
| D1206 |
Topical application of fluoride varnish |
908 |
885 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
734 |
707 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
329 |
105 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,593 |
912 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,317 |
1,275 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
428 |
419 |
$13K |
| D0274 |
Bitewings - four radiographic images |
522 |
498 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
371 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
192 |
63 |
$7K |
| D1353 |
|
326 |
49 |
$5K |
| D1110 |
Prophylaxis - adult |
134 |
127 |
$4K |
| D7250 |
|
112 |
24 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
165 |
137 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
41 |
$1K |
| D4346 |
|
14 |
14 |
$636.00 |
| D0270 |
|
45 |
45 |
$537.06 |
| D1999 |
|
494 |
433 |
$465.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$327.68 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$130.00 |