| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,199 |
549 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
587 |
278 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,560 |
1,548 |
$32K |
| D1120 |
Prophylaxis - child |
867 |
856 |
$22K |
| D0274 |
Bitewings - four radiographic images |
873 |
863 |
$21K |
| D1110 |
Prophylaxis - adult |
481 |
476 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,509 |
1,493 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,746 |
1,726 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,636 |
1,620 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
119 |
116 |
$12K |
| D0272 |
Bitewings - two radiographic images |
459 |
454 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
76 |
31 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
78 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
274 |
261 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
16 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
12 |
$1K |
| D0603 |
|
1,237 |
1,230 |
$0.00 |
| D0601 |
|
374 |
371 |
$0.00 |
| D0602 |
|
80 |
80 |
$0.00 |