| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,938 |
900 |
$69K |
| D1120 |
Prophylaxis - child |
1,419 |
1,406 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,690 |
1,671 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,944 |
1,919 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
180 |
82 |
$21K |
| D1110 |
Prophylaxis - adult |
507 |
495 |
$19K |
| D0272 |
Bitewings - two radiographic images |
982 |
967 |
$19K |
| D0274 |
Bitewings - four radiographic images |
425 |
416 |
$12K |
| D0330 |
Panoramic radiographic image |
277 |
277 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
389 |
364 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
118 |
94 |
$7K |
| D2140 |
|
85 |
70 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
141 |
$4K |
| D0240 |
|
164 |
159 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$725.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$352.20 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |