| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,914 |
1,167 |
$175K |
| D0145 |
Oral evaluation for a patient under three years of age |
813 |
810 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,409 |
3,350 |
$95K |
| D1120 |
Prophylaxis - child |
2,608 |
2,585 |
$93K |
| D1110 |
Prophylaxis - adult |
1,435 |
1,418 |
$76K |
| D0272 |
Bitewings - two radiographic images |
2,920 |
2,885 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,928 |
3,888 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,056 |
3,920 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,563 |
3,692 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
494 |
208 |
$45K |
| D0350 |
|
1,646 |
1,605 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
669 |
640 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
309 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
100 |
$14K |
| D0240 |
|
858 |
838 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
163 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
14 |
$1K |
| D1330 |
|
127 |
125 |
$967.75 |
| D0270 |
|
25 |
25 |
$107.80 |
| D0603 |
|
1,891 |
1,864 |
$36.36 |
| D0601 |
|
797 |
791 |
$22.00 |
| D0602 |
|
2,158 |
2,148 |
$9.03 |