| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,643 |
1,414 |
$159K |
| D1120 |
Prophylaxis - child |
2,472 |
2,306 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
3,037 |
2,765 |
$77K |
| D1206 |
Topical application of fluoride varnish |
3,051 |
2,823 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,824 |
1,695 |
$38K |
| D1110 |
Prophylaxis - adult |
560 |
516 |
$25K |
| D0274 |
Bitewings - four radiographic images |
687 |
630 |
$21K |
| D9248 |
|
205 |
193 |
$21K |
| D0330 |
Panoramic radiographic image |
356 |
337 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
88 |
42 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
107 |
54 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
60 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
768 |
685 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
429 |
372 |
$4K |
| D1330 |
|
492 |
430 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
52 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
26 |
$883.00 |
| D0603 |
|
3,506 |
3,283 |
$0.00 |