| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,700 |
896 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
888 |
541 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,785 |
2,732 |
$77K |
| D1120 |
Prophylaxis - child |
2,118 |
2,079 |
$75K |
| D0145 |
Oral evaluation for a patient under three years of age |
536 |
529 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,407 |
2,730 |
$59K |
| D1110 |
Prophylaxis - adult |
1,123 |
1,104 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,190 |
3,135 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,134 |
1,116 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,886 |
2,805 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
239 |
$26K |
| D0272 |
Bitewings - two radiographic images |
889 |
867 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
206 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
300 |
255 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$4K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$765.36 |
| D1330 |
|
17 |
15 |
$85.75 |
| D0603 |
|
241 |
239 |
$0.00 |
| D0602 |
|
3,416 |
3,376 |
$0.00 |