| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,244 |
1,075 |
$114K |
| D0145 |
Oral evaluation for a patient under three years of age |
684 |
678 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
3,215 |
3,176 |
$91K |
| D1120 |
Prophylaxis - child |
2,404 |
2,372 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
780 |
445 |
$77K |
| D1110 |
Prophylaxis - adult |
1,374 |
1,358 |
$73K |
| D0240 |
|
7,649 |
3,627 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,879 |
3,827 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,577 |
1,547 |
$50K |
| D0272 |
Bitewings - two radiographic images |
1,975 |
1,953 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
425 |
248 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
159 |
83 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
602 |
586 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
138 |
69 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
669 |
622 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
82 |
$1K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$708.74 |
| D1330 |
|
184 |
180 |
$125.00 |
| D0602 |
|
793 |
788 |
$9.06 |
| D0603 |
|
438 |
435 |
$0.09 |
| D0601 |
|
3,167 |
3,142 |
$0.05 |