| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
8,501 |
1,755 |
$222K |
| D0120 |
Periodic oral evaluation - established patient |
4,162 |
4,125 |
$117K |
| D1120 |
Prophylaxis - child |
2,940 |
2,904 |
$104K |
| D0145 |
Oral evaluation for a patient under three years of age |
700 |
698 |
$98K |
| D1110 |
Prophylaxis - adult |
1,848 |
1,825 |
$97K |
| D0274 |
Bitewings - four radiographic images |
2,911 |
2,869 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
810 |
412 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,736 |
4,667 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,656 |
1,749 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
598 |
316 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
2,169 |
2,115 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
739 |
676 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
538 |
526 |
$18K |
| D0272 |
Bitewings - two radiographic images |
350 |
347 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
12 |
$4K |
| D1330 |
|
178 |
178 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$523.89 |
| D0350 |
|
18 |
18 |
$238.94 |
| D0603 |
|
5,776 |
5,696 |
$0.02 |
| D0601 |
|
26 |
26 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |