| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
13,121 |
2,961 |
$362K |
| D1120 |
Prophylaxis - child |
7,569 |
7,561 |
$274K |
| D0120 |
Periodic oral evaluation - established patient |
9,418 |
9,395 |
$268K |
| D1206 |
Topical application of fluoride varnish |
9,505 |
9,497 |
$139K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
899 |
295 |
$133K |
| D0145 |
Oral evaluation for a patient under three years of age |
691 |
688 |
$97K |
| D1110 |
Prophylaxis - adult |
1,707 |
1,706 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
922 |
594 |
$90K |
| D0272 |
Bitewings - two radiographic images |
4,719 |
4,698 |
$85K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,709 |
2,662 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,673 |
4,837 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
1,107 |
1,106 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
5,783 |
5,702 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,869 |
1,869 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
435 |
285 |
$33K |
| D0330 |
Panoramic radiographic image |
1,257 |
1,255 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
20 |
$375.60 |
| D0603 |
|
11,861 |
11,825 |
$0.00 |