| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,801 |
1,128 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,114 |
558 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
3,097 |
3,063 |
$87K |
| D1120 |
Prophylaxis - child |
2,125 |
2,103 |
$76K |
| D0145 |
Oral evaluation for a patient under three years of age |
449 |
443 |
$62K |
| D1110 |
Prophylaxis - adult |
1,154 |
1,143 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,647 |
3,611 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,351 |
1,336 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
454 |
283 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,618 |
2,581 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,449 |
2,418 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
373 |
368 |
$25K |
| D0272 |
Bitewings - two radiographic images |
922 |
911 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
205 |
$7K |
| D1330 |
|
92 |
89 |
$955.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
17 |
$487.98 |
| D0603 |
|
4,714 |
4,676 |
$0.15 |