| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,484 |
1,038 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
4,325 |
4,287 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,220 |
302 |
$113K |
| D1120 |
Prophylaxis - child |
2,205 |
2,186 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,972 |
4,928 |
$70K |
| D1110 |
Prophylaxis - adult |
1,305 |
1,286 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,071 |
2,038 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
762 |
215 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,966 |
3,922 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,090 |
3,792 |
$43K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
139 |
$19K |
| D0272 |
Bitewings - two radiographic images |
618 |
615 |
$13K |
| D2330 |
|
138 |
57 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
72 |
12 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
175 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
45 |
12 |
$3K |
| D9248 |
|
36 |
36 |
$3K |
| D0330 |
Panoramic radiographic image |
111 |
107 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$917.04 |
| D0603 |
|
1,342 |
1,334 |
$0.13 |
| D0602 |
|
1,887 |
1,873 |
$0.06 |
| D0601 |
|
847 |
831 |
$0.01 |