| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,736 |
342 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
410 |
194 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
666 |
642 |
$18K |
| D2330 |
|
208 |
101 |
$15K |
| D1110 |
Prophylaxis - adult |
288 |
273 |
$15K |
| D1120 |
Prophylaxis - child |
368 |
362 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
67 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
712 |
689 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
817 |
791 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
68 |
$10K |
| D0274 |
Bitewings - four radiographic images |
281 |
266 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
67 |
31 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
779 |
756 |
$9K |
| D0272 |
Bitewings - two radiographic images |
329 |
325 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
90 |
87 |
$2K |
| D9248 |
|
14 |
14 |
$2K |
| D1330 |
|
39 |
38 |
$428.75 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$225.36 |
| D0603 |
|
800 |
773 |
$0.00 |