| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,493 |
940 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
975 |
463 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,698 |
2,592 |
$73K |
| D1110 |
Prophylaxis - adult |
1,211 |
1,154 |
$61K |
| D1120 |
Prophylaxis - child |
1,619 |
1,554 |
$55K |
| D0145 |
Oral evaluation for a patient under three years of age |
406 |
390 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,733 |
1,655 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,627 |
2,533 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,739 |
2,625 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,668 |
2,552 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
143 |
$17K |
| D0272 |
Bitewings - two radiographic images |
700 |
671 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
176 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
117 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$176.55 |
| D0603 |
|
2,651 |
2,576 |
$0.00 |
| D0602 |
|
515 |
504 |
$0.00 |
| D1999 |
|
2,240 |
1,982 |
$0.00 |