| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,331 |
615 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
650 |
248 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,130 |
2,072 |
$58K |
| D1120 |
Prophylaxis - child |
1,335 |
1,300 |
$46K |
| D1110 |
Prophylaxis - adult |
834 |
817 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,590 |
2,520 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,774 |
1,280 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,390 |
1,347 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
90 |
89 |
$13K |
| D0272 |
Bitewings - two radiographic images |
484 |
474 |
$11K |
| D0274 |
Bitewings - four radiographic images |
283 |
273 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
145 |
$5K |
| D0350 |
|
255 |
240 |
$4K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D1330 |
|
38 |
32 |
$98.00 |
| D0603 |
|
3,072 |
2,998 |
$0.00 |