| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,892 |
368 |
$41K |
| D1120 |
Prophylaxis - child |
1,057 |
1,037 |
$33K |
| D1110 |
Prophylaxis - adult |
737 |
731 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
811 |
796 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
229 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,114 |
1,103 |
$15K |
| D0330 |
Panoramic radiographic image |
132 |
130 |
$14K |
| D0274 |
Bitewings - four radiographic images |
656 |
649 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
515 |
514 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
856 |
762 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
91 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
19 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
944 |
927 |
$5K |
| D0272 |
Bitewings - two radiographic images |
687 |
668 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
85 |
58 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
58 |
$919.54 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
133 |
$388.27 |
| D1330 |
|
861 |
836 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
835 |
810 |
$0.00 |