| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,905 |
958 |
$153K |
| D1120 |
Prophylaxis - child |
4,727 |
2,818 |
$121K |
| D1206 |
Topical application of fluoride varnish |
6,358 |
3,732 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
5,491 |
3,228 |
$97K |
| D1354 |
|
1,251 |
126 |
$86K |
| D1110 |
Prophylaxis - adult |
1,861 |
1,032 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,162 |
381 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,502 |
1,449 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
218 |
39 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,185 |
743 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
897 |
528 |
$24K |
| D0240 |
|
2,260 |
476 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
728 |
450 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
278 |
167 |
$16K |
| D0330 |
Panoramic radiographic image |
666 |
374 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
479 |
232 |
$14K |
| D0274 |
Bitewings - four radiographic images |
569 |
249 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
587 |
264 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
14 |
$154.48 |
| D1999 |
|
1,875 |
694 |
$0.00 |