| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,844 |
1,142 |
$150K |
| D1120 |
Prophylaxis - child |
2,687 |
2,617 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,312 |
3,240 |
$91K |
| D0145 |
Oral evaluation for a patient under three years of age |
468 |
461 |
$63K |
| D1110 |
Prophylaxis - adult |
1,204 |
1,178 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
654 |
264 |
$61K |
| D0272 |
Bitewings - two radiographic images |
2,668 |
2,606 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,181 |
4,075 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
4,410 |
4,271 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,443 |
4,023 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,001 |
978 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
172 |
40 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
120 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
494 |
464 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
144 |
136 |
$4K |
| D9248 |
|
13 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
75 |
$1K |
| D0350 |
|
164 |
161 |
$1K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$370.07 |
| D0603 |
|
2,567 |
2,510 |
$0.00 |
| D0602 |
|
2,078 |
2,059 |
$0.00 |
| D0601 |
|
85 |
83 |
$0.00 |