| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,466 |
276 |
$38K |
| D0145 |
Oral evaluation for a patient under three years of age |
172 |
171 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,787 |
729 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
94 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
541 |
525 |
$14K |
| D1120 |
Prophylaxis - child |
410 |
400 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
884 |
860 |
$12K |
| D1110 |
Prophylaxis - adult |
214 |
210 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
816 |
772 |
$10K |
| D0274 |
Bitewings - four radiographic images |
245 |
239 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
24 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
128 |
$4K |
| D0601 |
|
352 |
346 |
$1.91 |
| D0603 |
|
669 |
657 |
$1.78 |