| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,050 |
537 |
$80K |
| D0145 |
Oral evaluation for a patient under three years of age |
464 |
455 |
$62K |
| D1120 |
Prophylaxis - child |
1,491 |
1,462 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,715 |
1,686 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
164 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
201 |
41 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,964 |
1,828 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,021 |
1,985 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,014 |
1,944 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
393 |
378 |
$23K |
| D1110 |
Prophylaxis - adult |
412 |
403 |
$21K |
| D0274 |
Bitewings - four radiographic images |
620 |
606 |
$20K |
| D0272 |
Bitewings - two radiographic images |
676 |
664 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
469 |
$15K |
| D9248 |
|
97 |
96 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
67 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
14 |
$4K |
| D0160 |
|
144 |
142 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
78 |
$2K |
| D1330 |
|
116 |
114 |
$1K |
| D0350 |
|
77 |
76 |
$1K |
| D0601 |
|
1,228 |
1,184 |
$12.03 |
| D0603 |
|
659 |
643 |
$0.13 |
| D0602 |
|
820 |
811 |
$0.01 |