| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,383 |
830 |
$114K |
| D1120 |
Prophylaxis - child |
2,823 |
2,779 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,298 |
3,235 |
$71K |
| D1206 |
Topical application of fluoride varnish |
3,707 |
3,631 |
$66K |
| D1110 |
Prophylaxis - adult |
944 |
920 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,849 |
1,083 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
318 |
199 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,733 |
1,636 |
$21K |
| D0330 |
Panoramic radiographic image |
431 |
415 |
$17K |
| D0274 |
Bitewings - four radiographic images |
573 |
562 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
151 |
101 |
$16K |
| D0272 |
Bitewings - two radiographic images |
831 |
819 |
$15K |
| D1353 |
|
426 |
135 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
90 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
278 |
264 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
161 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
56 |
$4K |
| D1354 |
|
625 |
238 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
110 |
109 |
$3K |
| D0240 |
|
196 |
173 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
137 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
39 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$782.99 |