| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,718 |
1,087 |
$147K |
| D0145 |
Oral evaluation for a patient under three years of age |
912 |
908 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,833 |
3,604 |
$76K |
| D1120 |
Prophylaxis - child |
2,647 |
2,600 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
3,180 |
3,123 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
835 |
363 |
$57K |
| D1110 |
Prophylaxis - adult |
1,098 |
1,081 |
$46K |
| D1206 |
Topical application of fluoride varnish |
3,842 |
3,778 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,652 |
1,624 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
4,012 |
3,900 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
353 |
172 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
692 |
654 |
$18K |
| D0272 |
Bitewings - two radiographic images |
833 |
821 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
150 |
147 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
198 |
183 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
17 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
54 |
$902.40 |
| D0603 |
|
3,619 |
3,577 |
$0.20 |
| D0602 |
|
68 |
67 |
$0.00 |
| D0601 |
|
1,164 |
1,132 |
$0.00 |