| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
613 |
295 |
$44K |
| D4342 |
|
388 |
164 |
$44K |
| D1120 |
Prophylaxis - child |
1,371 |
1,297 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,368 |
1,300 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
507 |
282 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
591 |
485 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
778 |
574 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,489 |
1,365 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,045 |
955 |
$12K |
| D4341 |
|
83 |
27 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
656 |
600 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,002 |
1,801 |
$11K |
| D1110 |
Prophylaxis - adult |
291 |
284 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,669 |
1,507 |
$5K |
| D0330 |
Panoramic radiographic image |
167 |
151 |
$3K |
| D0272 |
Bitewings - two radiographic images |
330 |
291 |
$3K |
| D2330 |
|
32 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
100 |
$587.64 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
18 |
$32.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
24 |
$0.00 |