| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
17,752 |
2,259 |
$455K |
| D0274 |
Bitewings - four radiographic images |
6,196 |
5,984 |
$167K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,774 |
973 |
$132K |
| D1110 |
Prophylaxis - adult |
3,156 |
3,005 |
$125K |
| D1120 |
Prophylaxis - child |
3,777 |
3,694 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
4,890 |
4,743 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,977 |
4,846 |
$87K |
| D0330 |
Panoramic radiographic image |
1,462 |
1,402 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
4,578 |
4,258 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,288 |
1,228 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,055 |
2,816 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
519 |
484 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
448 |
375 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
46 |
$5K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$769.59 |