| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,702 |
1,497 |
$146K |
| D1120 |
Prophylaxis - child |
4,288 |
3,994 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
5,697 |
5,320 |
$106K |
| D1206 |
Topical application of fluoride varnish |
5,950 |
5,532 |
$105K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
714 |
231 |
$77K |
| D1110 |
Prophylaxis - adult |
1,684 |
1,562 |
$64K |
| D0272 |
Bitewings - two radiographic images |
2,876 |
2,670 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,592 |
1,457 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
769 |
646 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,069 |
962 |
$25K |
| D1354 |
|
309 |
109 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
401 |
181 |
$22K |
| D0330 |
Panoramic radiographic image |
734 |
685 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
362 |
323 |
$10K |
| D0240 |
|
197 |
113 |
$3K |
| D0274 |
Bitewings - four radiographic images |
76 |
70 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
121 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
12 |
$160.00 |