| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,194 |
1,323 |
$141K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,074 |
5,572 |
$130K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,194 |
1,167 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,683 |
899 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
4,958 |
4,841 |
$110K |
| D1120 |
Prophylaxis - child |
3,685 |
3,615 |
$99K |
| D1110 |
Prophylaxis - adult |
1,807 |
1,777 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,563 |
2,508 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
6,487 |
6,278 |
$60K |
| D1206 |
Topical application of fluoride varnish |
5,385 |
5,287 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
784 |
361 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
507 |
324 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,001 |
962 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
170 |
94 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
746 |
701 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
199 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
417 |
409 |
$8K |
| D0272 |
Bitewings - two radiographic images |
394 |
385 |
$8K |
| D0603 |
|
4,230 |
4,171 |
$683.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$189.77 |
| D0602 |
|
1,421 |
1,399 |
$157.52 |
| D0601 |
|
1,476 |
1,446 |
$117.46 |