| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
10,804 |
1,906 |
$179K |
| D1110 |
Prophylaxis - adult |
3,054 |
3,041 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,878 |
928 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
3,886 |
3,871 |
$76K |
| D0274 |
Bitewings - four radiographic images |
3,308 |
3,290 |
$67K |
| D1120 |
Prophylaxis - child |
2,779 |
2,765 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,782 |
5,758 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
672 |
405 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
554 |
543 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,314 |
1,308 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,120 |
2,109 |
$28K |
| D0330 |
Panoramic radiographic image |
1,086 |
1,078 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,752 |
1,717 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,521 |
1,425 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
166 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
26 |
$5K |
| D9970 |
|
72 |
72 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$544.10 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
25 |
$300.91 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$102.90 |
| D9910 |
|
580 |
34 |
$17.91 |
| D0603 |
|
3,124 |
3,116 |
$0.00 |
| D0602 |
|
2,259 |
2,234 |
$0.00 |
| D0601 |
|
236 |
236 |
$0.00 |
| D1999 |
|
17 |
16 |
$0.00 |