| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,930 |
1,560 |
$118K |
| D1110 |
Prophylaxis - adult |
3,011 |
2,980 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
4,608 |
4,552 |
$90K |
| D1120 |
Prophylaxis - child |
3,006 |
2,970 |
$72K |
| D0274 |
Bitewings - four radiographic images |
3,382 |
3,346 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,800 |
5,734 |
$56K |
| D0145 |
Oral evaluation for a patient under three years of age |
688 |
682 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
909 |
661 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,450 |
1,431 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,300 |
2,271 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
411 |
224 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
3,077 |
3,019 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,789 |
2,649 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
281 |
281 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
152 |
77 |
$16K |
| D0330 |
Panoramic radiographic image |
1,228 |
1,211 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
65 |
65 |
$668.85 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$475.89 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$135.54 |
| D0603 |
|
4,328 |
4,249 |
$0.00 |
| D0601 |
|
334 |
321 |
$0.00 |
| D0602 |
|
2,066 |
2,031 |
$0.00 |
| D1999 |
|
66 |
54 |
$0.00 |