| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,571 |
765 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,875 |
2,855 |
$79K |
| D1120 |
Prophylaxis - child |
2,151 |
2,135 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
716 |
433 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,947 |
2,924 |
$42K |
| D1110 |
Prophylaxis - adult |
734 |
728 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
209 |
208 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,230 |
1,217 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
158 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
844 |
823 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,799 |
1,777 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,850 |
1,693 |
$20K |
| D0330 |
Panoramic radiographic image |
214 |
213 |
$12K |
| D0274 |
Bitewings - four radiographic images |
307 |
306 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
12 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$420.10 |
| D0350 |
|
12 |
12 |
$202.18 |
| D0603 |
|
3,477 |
3,462 |
$0.00 |