| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,393 |
238 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,113 |
1,090 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
114 |
$28K |
| D1120 |
Prophylaxis - child |
763 |
743 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,073 |
926 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
166 |
164 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,653 |
1,613 |
$23K |
| D1110 |
Prophylaxis - adult |
446 |
433 |
$23K |
| D0274 |
Bitewings - four radiographic images |
810 |
790 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,170 |
1,108 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
314 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
103 |
100 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$847.68 |
| D0601 |
|
761 |
755 |
$0.00 |
| D0603 |
|
917 |
899 |
$0.00 |
| D0602 |
|
80 |
78 |
$0.00 |