| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,198 |
409 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,432 |
1,415 |
$40K |
| D1120 |
Prophylaxis - child |
948 |
941 |
$34K |
| D1110 |
Prophylaxis - adult |
544 |
531 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,005 |
993 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,448 |
1,431 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
136 |
79 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
105 |
$14K |
| D0330 |
Panoramic radiographic image |
173 |
172 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
417 |
386 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
48 |
48 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
29 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
98 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$713.64 |
| D0603 |
|
832 |
823 |
$0.00 |
| D0601 |
|
565 |
560 |
$0.00 |
| D0602 |
|
216 |
212 |
$0.00 |