| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,294 |
642 |
$81K |
| D0145 |
Oral evaluation for a patient under three years of age |
429 |
388 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,689 |
1,649 |
$46K |
| D1120 |
Prophylaxis - child |
1,358 |
1,313 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
221 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
348 |
226 |
$26K |
| D0272 |
Bitewings - two radiographic images |
932 |
898 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
137 |
63 |
$19K |
| D1110 |
Prophylaxis - adult |
362 |
355 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,301 |
1,255 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
589 |
545 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,170 |
1,095 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,095 |
978 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
148 |
$10K |
| D0274 |
Bitewings - four radiographic images |
259 |
249 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
76 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
360 |
$5K |
| D9248 |
|
25 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
65 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
62 |
$1K |
| D0330 |
Panoramic radiographic image |
22 |
19 |
$868.16 |
| D1999 |
|
542 |
494 |
$0.00 |
| D0603 |
|
2,372 |
2,287 |
$0.00 |