| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,896 |
705 |
$104K |
| D1120 |
Prophylaxis - child |
1,607 |
1,584 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,639 |
1,613 |
$43K |
| D0145 |
Oral evaluation for a patient under three years of age |
246 |
242 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,468 |
2,431 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,500 |
2,454 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,649 |
2,257 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
183 |
68 |
$26K |
| D1110 |
Prophylaxis - adult |
487 |
476 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,166 |
1,153 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
234 |
113 |
$22K |
| D0274 |
Bitewings - four radiographic images |
617 |
606 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
481 |
$16K |
| D9248 |
|
109 |
105 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
49 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
174 |
150 |
$4K |
| D0330 |
Panoramic radiographic image |
200 |
198 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$835.12 |
| D0603 |
|
3,320 |
3,244 |
$0.00 |