| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,104 |
226 |
$27K |
| D1120 |
Prophylaxis - child |
543 |
541 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
556 |
556 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
602 |
583 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
66 |
$8K |
| D1206 |
Topical application of fluoride varnish |
356 |
341 |
$6K |
| D1110 |
Prophylaxis - adult |
117 |
117 |
$5K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$5K |
| D0272 |
Bitewings - two radiographic images |
225 |
225 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
31 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
114 |
108 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
161 |
58 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
47 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
94 |
$1K |
| D0240 |
|
65 |
49 |
$1K |
| D9420 |
|
13 |
12 |
$900.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$319.00 |