| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,405 |
908 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,161 |
3,107 |
$87K |
| D1110 |
Prophylaxis - adult |
1,247 |
1,227 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,738 |
1,695 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,467 |
3,403 |
$49K |
| D1120 |
Prophylaxis - child |
1,396 |
1,369 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
3,492 |
3,404 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,645 |
3,280 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
83 |
$14K |
| D0272 |
Bitewings - two radiographic images |
500 |
486 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
114 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
24 |
$3K |
| D0602 |
|
380 |
377 |
$0.00 |
| D0603 |
|
2,310 |
2,243 |
$0.00 |
| D0601 |
|
135 |
132 |
$0.00 |