| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,395 |
1,033 |
$118K |
| D1110 |
Prophylaxis - adult |
1,750 |
1,744 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
831 |
281 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,271 |
2,266 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,637 |
1,633 |
$55K |
| D1120 |
Prophylaxis - child |
1,262 |
1,261 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,040 |
3,032 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
703 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,852 |
1,832 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,277 |
1,275 |
$19K |
| D0330 |
Panoramic radiographic image |
518 |
518 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,679 |
1,527 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
123 |
123 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0603 |
|
3,019 |
2,998 |
$0.00 |
| D0602 |
|
179 |
179 |
$0.00 |