| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,065 |
416 |
$55K |
| D1120 |
Prophylaxis - child |
1,087 |
1,077 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,123 |
1,073 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
547 |
187 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
697 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,774 |
933 |
$22K |
| D0330 |
Panoramic radiographic image |
639 |
634 |
$20K |
| D2335 |
|
251 |
57 |
$18K |
| D0274 |
Bitewings - four radiographic images |
838 |
834 |
$18K |
| D3120 |
|
633 |
178 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
895 |
880 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
312 |
308 |
$8K |
| D2394 |
|
149 |
67 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
491 |
396 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$928.35 |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$904.05 |
| D0603 |
|
134 |
132 |
$677.25 |
| D1353 |
|
64 |
13 |
$637.14 |
| D0999 |
Unspecified diagnostic procedure, by report |
21 |
21 |
$630.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
21 |
21 |
$420.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$205.00 |