| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,729 |
802 |
$119K |
| D1120 |
Prophylaxis - child |
2,645 |
2,598 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,285 |
3,235 |
$89K |
| D0145 |
Oral evaluation for a patient under three years of age |
566 |
564 |
$79K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
533 |
180 |
$73K |
| D1206 |
Topical application of fluoride varnish |
3,145 |
3,093 |
$43K |
| D1110 |
Prophylaxis - adult |
772 |
764 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
242 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,543 |
1,765 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,173 |
1,140 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
200 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,053 |
1,987 |
$23K |
| D0330 |
Panoramic radiographic image |
388 |
386 |
$21K |
| D0274 |
Bitewings - four radiographic images |
477 |
470 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
374 |
350 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
158 |
83 |
$8K |
| D9420 |
|
143 |
142 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
97 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
204 |
201 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
59 |
$1K |
| D0603 |
|
4,237 |
4,171 |
$0.00 |