| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,131 |
819 |
$106K |
| D1120 |
Prophylaxis - child |
2,408 |
2,353 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,116 |
2,075 |
$59K |
| D0272 |
Bitewings - two radiographic images |
2,085 |
2,013 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,738 |
2,675 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
3,240 |
3,097 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,084 |
2,953 |
$33K |
| D0145 |
Oral evaluation for a patient under three years of age |
208 |
204 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
177 |
56 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
585 |
537 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
398 |
$13K |
| D0274 |
Bitewings - four radiographic images |
389 |
377 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
50 |
$8K |
| D1110 |
Prophylaxis - adult |
43 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0240 |
|
120 |
111 |
$678.36 |
| D0603 |
|
3,320 |
3,238 |
$0.00 |
| D0602 |
|
100 |
94 |
$0.00 |