| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,060 |
1,431 |
$78K |
| D0140 |
Limited oral evaluation - problem focused |
2,923 |
2,892 |
$58K |
| D1120 |
Prophylaxis - child |
1,968 |
1,951 |
$55K |
| D1110 |
Prophylaxis - adult |
1,111 |
1,104 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
329 |
253 |
$13K |
| D0330 |
Panoramic radiographic image |
253 |
253 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
400 |
289 |
$7K |
| D1206 |
Topical application of fluoride varnish |
3,712 |
3,666 |
$6K |
| D9996 |
|
2,408 |
2,392 |
$5K |
| D0350 |
|
2,513 |
2,503 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
581 |
578 |
$2K |
| D0274 |
Bitewings - four radiographic images |
492 |
491 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
35 |
35 |
$2K |
| D0191 |
|
1,005 |
984 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
680 |
679 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
39 |
39 |
$975.00 |
| D1330 |
|
4,186 |
4,129 |
$596.52 |
| D0999 |
Unspecified diagnostic procedure, by report |
17 |
17 |
$340.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$304.06 |
| D0220 |
Intraoral - periapical first radiographic image |
874 |
863 |
$69.40 |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$13.00 |
| 1159F |
|
494 |
467 |
$0.00 |
| 1160F |
|
494 |
467 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
28 |
$0.00 |
| D1310 |
|
1,835 |
1,818 |
$0.00 |
| D0603 |
|
207 |
205 |
$0.00 |
| 1126F |
|
471 |
446 |
$0.00 |