| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,924 |
1,049 |
$133K |
| D1110 |
Prophylaxis - adult |
2,390 |
2,362 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
4,459 |
4,404 |
$122K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,853 |
4,871 |
$115K |
| D1120 |
Prophylaxis - child |
2,917 |
2,887 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,005 |
459 |
$95K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,585 |
5,523 |
$79K |
| D0145 |
Oral evaluation for a patient under three years of age |
595 |
587 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,101 |
2,072 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
5,289 |
5,214 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
952 |
939 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
193 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
314 |
307 |
$21K |
| D0272 |
Bitewings - two radiographic images |
910 |
896 |
$20K |
| D1330 |
|
144 |
128 |
$808.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$352.43 |
| D0603 |
|
6,256 |
6,202 |
$0.00 |
| D0601 |
|
43 |
43 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |
| D9911 |
|
20 |
12 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |
| D1310 |
|
65 |
60 |
$0.00 |