| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,936 |
338 |
$53K |
| D1120 |
Prophylaxis - child |
947 |
924 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,015 |
988 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
171 |
$24K |
| D9248 |
|
196 |
191 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
117 |
$20K |
| D0272 |
Bitewings - two radiographic images |
750 |
729 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,151 |
1,120 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
19 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
138 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
38 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
78 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
270 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
69 |
$780.38 |
| D0603 |
|
660 |
654 |
$0.00 |
| D0601 |
|
708 |
700 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |