| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,641 |
692 |
$120K |
| D9920 |
|
686 |
663 |
$85K |
| D1120 |
Prophylaxis - child |
1,328 |
1,311 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,962 |
1,926 |
$38K |
| D1110 |
Prophylaxis - adult |
698 |
682 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
981 |
959 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
915 |
899 |
$20K |
| D0274 |
Bitewings - four radiographic images |
557 |
541 |
$17K |
| D0272 |
Bitewings - two radiographic images |
557 |
552 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
65 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
37 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
144 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
114 |
113 |
$3K |
| D1310 |
|
182 |
182 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
116 |
$1K |
| D1330 |
|
100 |
100 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$618.42 |
| D1999 |
|
82 |
82 |
$567.00 |
| D1354 |
|
53 |
14 |
$560.00 |
| D0603 |
|
18 |
18 |
$180.00 |