| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,382 |
235 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
271 |
113 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
110 |
109 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
367 |
353 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,056 |
377 |
$10K |
| D1120 |
Prophylaxis - child |
263 |
256 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
390 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
324 |
317 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
13 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
95 |
$3K |
| D0272 |
Bitewings - two radiographic images |
82 |
81 |
$2K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$375.05 |
| D0603 |
|
515 |
502 |
$0.03 |