| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,982 |
571 |
$77K |
| D1120 |
Prophylaxis - child |
2,004 |
1,985 |
$65K |
| D9920 |
|
481 |
463 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
561 |
195 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,554 |
2,508 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,289 |
1,266 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,067 |
1,066 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
426 |
380 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,051 |
1,042 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
145 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
149 |
$15K |
| D1110 |
Prophylaxis - adult |
326 |
319 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
116 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
181 |
$6K |
| D1310 |
|
601 |
600 |
$6K |
| D1330 |
|
592 |
591 |
$6K |
| D0274 |
Bitewings - four radiographic images |
201 |
199 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
567 |
554 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
284 |
176 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
88 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
71 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$1K |
| D1354 |
|
39 |
14 |
$545.00 |