| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
11,128 |
1,291 |
$282K |
| D1120 |
Prophylaxis - child |
2,993 |
2,953 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,811 |
2,699 |
$70K |
| D1206 |
Topical application of fluoride varnish |
3,612 |
3,551 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,808 |
1,786 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,915 |
1,880 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,916 |
2,860 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,053 |
1,033 |
$32K |
| D1110 |
Prophylaxis - adult |
655 |
645 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
795 |
726 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
663 |
609 |
$23K |
| D0330 |
Panoramic radiographic image |
738 |
718 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
270 |
187 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
248 |
100 |
$21K |
| D0272 |
Bitewings - two radiographic images |
862 |
851 |
$18K |
| D9920 |
|
34 |
31 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
12 |
$6K |
| D0240 |
|
94 |
49 |
$1K |