| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,821 |
642 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
537 |
275 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
320 |
100 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,538 |
1,528 |
$33K |
| D1120 |
Prophylaxis - child |
1,013 |
1,007 |
$27K |
| D0274 |
Bitewings - four radiographic images |
754 |
749 |
$19K |
| D1110 |
Prophylaxis - adult |
445 |
441 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,665 |
1,653 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,703 |
1,684 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
138 |
138 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,615 |
1,604 |
$14K |
| D0272 |
Bitewings - two radiographic images |
686 |
683 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
67 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
182 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
25 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$540.40 |
| D0603 |
|
1,458 |
1,448 |
$0.00 |
| D0601 |
|
222 |
220 |
$0.00 |
| D0602 |
|
155 |
155 |
$0.00 |