| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,436 |
1,135 |
$125K |
| D1120 |
Prophylaxis - child |
1,597 |
1,582 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,733 |
2,706 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
555 |
348 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,825 |
1,805 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
973 |
936 |
$36K |
| D1110 |
Prophylaxis - adult |
564 |
559 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
564 |
560 |
$16K |
| D0272 |
Bitewings - two radiographic images |
820 |
812 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,251 |
1,223 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
218 |
166 |
$15K |
| D0274 |
Bitewings - four radiographic images |
977 |
964 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
247 |
$7K |
| D0330 |
Panoramic radiographic image |
406 |
404 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
27 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
127 |
109 |
$3K |
| D0270 |
|
37 |
37 |
$490.00 |
| D1354 |
|
396 |
111 |
$0.00 |
| D0191 |
|
19 |
19 |
$0.00 |
| D1330 |
|
1,185 |
1,172 |
$0.00 |
| D1310 |
|
1,078 |
1,065 |
$0.00 |
| D9215 |
|
20 |
17 |
$0.00 |