| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,742 |
425 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
211 |
$21K |
| D1120 |
Prophylaxis - child |
821 |
816 |
$15K |
| D1110 |
Prophylaxis - adult |
526 |
526 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
942 |
936 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
306 |
187 |
$12K |
| D0274 |
Bitewings - four radiographic images |
651 |
651 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
153 |
153 |
$11K |
| D1206 |
Topical application of fluoride varnish |
1,337 |
1,330 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,383 |
1,366 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,342 |
1,299 |
$8K |
| D0272 |
Bitewings - two radiographic images |
611 |
607 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
401 |
401 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
349 |
314 |
$5K |
| D0330 |
Panoramic radiographic image |
315 |
314 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
32 |
$300.48 |
| D0603 |
|
1,423 |
1,416 |
$0.00 |
| D0602 |
|
32 |
32 |
$0.00 |