| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
10,071 |
2,340 |
$274K |
| D0120 |
Periodic oral evaluation - established patient |
7,795 |
7,746 |
$222K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,493 |
1,485 |
$209K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,903 |
805 |
$188K |
| D1120 |
Prophylaxis - child |
4,839 |
4,807 |
$176K |
| D1110 |
Prophylaxis - adult |
3,089 |
3,069 |
$167K |
| D0274 |
Bitewings - four radiographic images |
4,272 |
4,243 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,084 |
8,027 |
$117K |
| D0272 |
Bitewings - two radiographic images |
2,293 |
2,275 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
4,074 |
4,028 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,794 |
3,769 |
$43K |
| D9248 |
|
332 |
316 |
$38K |
| D0330 |
Panoramic radiographic image |
446 |
443 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
356 |
336 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
108 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$3K |
| D1330 |
|
250 |
248 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$469.50 |
| D0603 |
|
9,691 |
9,619 |
$0.00 |