| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,987 |
491 |
$54K |
| D1120 |
Prophylaxis - child |
1,280 |
1,265 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,462 |
1,448 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
291 |
289 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,653 |
1,635 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,039 |
1,026 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,132 |
1,695 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,803 |
1,774 |
$20K |
| D1110 |
Prophylaxis - adult |
335 |
331 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
198 |
119 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
91 |
$15K |
| D0274 |
Bitewings - four radiographic images |
330 |
326 |
$10K |
| D9248 |
|
59 |
58 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
152 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
196 |
189 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
17 |
$4K |
| D0330 |
Panoramic radiographic image |
216 |
210 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$225.36 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$160.23 |
| D0603 |
|
2,129 |
2,106 |
$0.00 |