| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,146 |
801 |
$95K |
| D1110 |
Prophylaxis - adult |
844 |
817 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,348 |
1,305 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
358 |
214 |
$25K |
| D1120 |
Prophylaxis - child |
789 |
763 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,232 |
1,174 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
968 |
873 |
$19K |
| D0274 |
Bitewings - four radiographic images |
621 |
596 |
$17K |
| D0330 |
Panoramic radiographic image |
460 |
447 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
384 |
348 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
14 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
673 |
622 |
$8K |
| D0272 |
Bitewings - two radiographic images |
308 |
298 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
203 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
42 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
310 |
270 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
28 |
$3K |
| D2954 |
|
16 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D0270 |
|
46 |
45 |
$602.00 |