| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,457 |
1,275 |
$91K |
| D1120 |
Prophylaxis - child |
3,395 |
2,957 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,110 |
4,478 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
4,691 |
4,119 |
$82K |
| D1110 |
Prophylaxis - adult |
1,583 |
1,398 |
$61K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,568 |
2,000 |
$56K |
| D0272 |
Bitewings - two radiographic images |
3,230 |
2,824 |
$56K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
226 |
142 |
$15K |
| D2140 |
|
377 |
217 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
76 |
24 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
42 |
$2K |
| D0240 |
|
155 |
52 |
$2K |
| D0330 |
Panoramic radiographic image |
68 |
47 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
33 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
18 |
$198.75 |