| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,729 |
678 |
$63K |
| D1120 |
Prophylaxis - child |
997 |
980 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,144 |
1,131 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,354 |
1,332 |
$22K |
| D1110 |
Prophylaxis - adult |
390 |
377 |
$15K |
| D0272 |
Bitewings - two radiographic images |
735 |
726 |
$14K |
| D0274 |
Bitewings - four radiographic images |
412 |
400 |
$11K |
| D2140 |
|
211 |
149 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
539 |
467 |
$10K |
| D0330 |
Panoramic radiographic image |
288 |
281 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
149 |
94 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
33 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
171 |
$5K |
| D0240 |
|
187 |
172 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
77 |
$855.46 |
| D1330 |
|
84 |
83 |
$0.00 |
| D1310 |
|
84 |
83 |
$0.00 |
| D0603 |
|
84 |
83 |
$0.00 |
| D1320 |
|
20 |
20 |
$0.00 |