| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,180 |
336 |
$29K |
| D1120 |
Prophylaxis - child |
945 |
943 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,255 |
1,246 |
$27K |
| D0145 |
Oral evaluation for a patient under three years of age |
205 |
203 |
$26K |
| D1110 |
Prophylaxis - adult |
437 |
431 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,066 |
1,060 |
$11K |
| D0330 |
Panoramic radiographic image |
315 |
310 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
858 |
253 |
$8K |
| D0274 |
Bitewings - four radiographic images |
290 |
285 |
$7K |
| D0272 |
Bitewings - two radiographic images |
331 |
322 |
$6K |
| D1206 |
Topical application of fluoride varnish |
330 |
328 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
369 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
105 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
70 |
68 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$281.70 |
| D0350 |
|
63 |
12 |
$216.88 |
| D0270 |
|
13 |
13 |
$63.21 |
| D0603 |
|
1,648 |
1,637 |
$0.00 |