| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,964 |
1,047 |
$133K |
| D0145 |
Oral evaluation for a patient under three years of age |
734 |
727 |
$102K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
686 |
202 |
$94K |
| D1120 |
Prophylaxis - child |
2,538 |
2,505 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,505 |
2,475 |
$70K |
| D0272 |
Bitewings - two radiographic images |
2,362 |
2,337 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,929 |
2,894 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,074 |
3,015 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,914 |
2,865 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
804 |
765 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
104 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
397 |
390 |
$13K |
| D0274 |
Bitewings - four radiographic images |
317 |
315 |
$10K |
| D1110 |
Prophylaxis - adult |
137 |
135 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
37 |
$5K |
| D0603 |
|
3,549 |
3,529 |
$0.00 |
| D0602 |
|
220 |
218 |
$0.00 |