| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,938 |
1,208 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
846 |
309 |
$85K |
| D1120 |
Prophylaxis - child |
2,095 |
2,093 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,432 |
2,431 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,974 |
2,970 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,828 |
1,826 |
$42K |
| D1110 |
Prophylaxis - adult |
778 |
776 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,106 |
1,104 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,831 |
2,824 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,804 |
2,793 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
893 |
878 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
160 |
43 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
208 |
82 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
388 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
78 |
78 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
32 |
$7K |
| D0603 |
|
3,317 |
3,313 |
$0.00 |