| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,212 |
813 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
2,724 |
2,603 |
$72K |
| D1110 |
Prophylaxis - adult |
1,447 |
1,379 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,829 |
1,742 |
$54K |
| D1120 |
Prophylaxis - child |
1,537 |
1,461 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,999 |
2,858 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,683 |
1,593 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,553 |
1,418 |
$16K |
| D0272 |
Bitewings - two radiographic images |
800 |
759 |
$16K |
| D0330 |
Panoramic radiographic image |
431 |
415 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
378 |
312 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
41 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
83 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D1330 |
|
31 |
25 |
$269.50 |
| D0601 |
|
1,832 |
1,751 |
$0.00 |
| D0602 |
|
653 |
626 |
$0.00 |
| D0603 |
|
577 |
538 |
$0.00 |