| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,038 |
165 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,153 |
1,104 |
$22K |
| D1110 |
Prophylaxis - adult |
536 |
536 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
90 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
198 |
69 |
$13K |
| D1120 |
Prophylaxis - child |
401 |
401 |
$10K |
| D0274 |
Bitewings - four radiographic images |
568 |
568 |
$10K |
| 90686 |
|
571 |
520 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
57 |
$5K |
| D1354 |
|
442 |
110 |
$4K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$2K |
| 90651 |
|
112 |
104 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
219 |
$1K |
| 91322 |
|
13 |
12 |
$1K |
| D4355 |
|
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$1K |
| 90734 |
|
89 |
80 |
$1K |
| 90715 |
|
95 |
83 |
$962.38 |
| 90480 |
|
100 |
93 |
$936.65 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
144 |
130 |
$766.20 |
| 90707 |
|
44 |
43 |
$689.15 |
| 90633 |
|
49 |
48 |
$590.95 |
| 90716 |
|
42 |
40 |
$437.33 |
| 91320 |
|
22 |
21 |
$414.26 |
| 0064A |
|
50 |
50 |
$372.50 |
| 0134A |
|
13 |
12 |
$308.26 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$308.00 |
| 90662 |
|
41 |
31 |
$306.31 |
| D1999 |
|
31 |
29 |
$290.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
28 |
$260.00 |
| 0124A |
|
39 |
34 |
$219.06 |
| 90670 |
|
15 |
15 |
$190.50 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$169.00 |
| 90688 |
|
26 |
26 |
$142.64 |
| 0012A |
|
28 |
28 |
$85.17 |
| 0011A |
|
26 |
26 |
$75.46 |
| G0008 |
Administration of influenza virus vaccine |
197 |
186 |
$14.12 |
| 91301 |
|
125 |
125 |
$0.00 |
| 91312 |
|
39 |
34 |
$0.00 |
| 91300 |
|
24 |
24 |
$0.00 |