| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,397 |
583 |
$85K |
| D0145 |
Oral evaluation for a patient under three years of age |
459 |
446 |
$61K |
| D1120 |
Prophylaxis - child |
1,700 |
1,620 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,359 |
2,109 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
296 |
68 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
428 |
182 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,202 |
1,164 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,968 |
1,876 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,349 |
2,197 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
588 |
540 |
$18K |
| D0272 |
Bitewings - two radiographic images |
831 |
786 |
$18K |
| D9248 |
|
63 |
60 |
$7K |
| D1110 |
Prophylaxis - adult |
139 |
130 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
229 |
203 |
$6K |
| D0274 |
Bitewings - four radiographic images |
135 |
129 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
16 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D0330 |
Panoramic radiographic image |
45 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
57 |
$1K |
| D1330 |
|
43 |
43 |
$172.00 |
| D0602 |
|
2,172 |
2,073 |
$0.00 |
| D0603 |
|
624 |
591 |
$0.00 |