| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,499 |
279 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
209 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
929 |
857 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
1,030 |
566 |
$32K |
| D1120 |
Prophylaxis - child |
642 |
601 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
164 |
100 |
$20K |
| D1206 |
Topical application of fluoride varnish |
820 |
765 |
$19K |
| D1354 |
|
405 |
125 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
78 |
$10K |
| D0272 |
Bitewings - two radiographic images |
367 |
331 |
$9K |
| D1110 |
Prophylaxis - adult |
164 |
155 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
484 |
427 |
$6K |
| D0330 |
Panoramic radiographic image |
131 |
121 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
205 |
196 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
297 |
253 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
14 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
89 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
114 |
95 |
$3K |
| D4346 |
|
15 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
39 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$463.68 |