| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,871 |
1,002 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,012 |
1,987 |
$42K |
| D1120 |
Prophylaxis - child |
1,479 |
1,461 |
$39K |
| D1110 |
Prophylaxis - adult |
735 |
727 |
$29K |
| D0145 |
Oral evaluation for a patient under three years of age |
262 |
262 |
$28K |
| D0274 |
Bitewings - four radiographic images |
998 |
984 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,285 |
2,255 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
212 |
65 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,289 |
2,253 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,162 |
2,129 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,010 |
998 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
68 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
374 |
351 |
$7K |
| D0330 |
Panoramic radiographic image |
104 |
103 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
164 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$215.97 |
| D0603 |
|
2,332 |
2,300 |
$0.00 |
| D0602 |
|
280 |
279 |
$0.00 |