| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,750 |
315 |
$47K |
| D0145 |
Oral evaluation for a patient under three years of age |
299 |
293 |
$41K |
| D1120 |
Prophylaxis - child |
1,141 |
1,096 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
956 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,351 |
1,470 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,014 |
973 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,698 |
1,614 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,139 |
1,098 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
41 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
180 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
99 |
94 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
132 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$478.98 |
| D1330 |
|
498 |
493 |
$60.03 |
| D0603 |
|
1,939 |
1,904 |
$0.00 |
| D1999 |
|
676 |
600 |
$0.00 |