| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
14,179 |
2,443 |
$344K |
| D1351 |
Sealant - per tooth |
10,898 |
1,593 |
$314K |
| D1120 |
Prophylaxis - child |
3,098 |
2,960 |
$135K |
| D2940 |
|
2,240 |
900 |
$119K |
| D1206 |
Topical application of fluoride varnish |
3,518 |
3,354 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,185 |
2,078 |
$64K |
| D1355 |
|
2,866 |
663 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
835 |
790 |
$49K |
| D1310 |
|
1,803 |
1,773 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,338 |
1,270 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
302 |
165 |
$36K |
| D0330 |
Panoramic radiographic image |
393 |
372 |
$30K |
| D1110 |
Prophylaxis - adult |
487 |
458 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
273 |
$15K |
| D0274 |
Bitewings - four radiographic images |
175 |
153 |
$6K |
| D1330 |
|
288 |
267 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
46 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$348.00 |
| D0603 |
|
363 |
300 |
$0.00 |