| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,812 |
695 |
$73K |
| D1120 |
Prophylaxis - child |
1,663 |
1,656 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,111 |
2,100 |
$59K |
| D1110 |
Prophylaxis - adult |
972 |
968 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,500 |
1,491 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,718 |
2,707 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,157 |
2,535 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,630 |
2,603 |
$32K |
| D0272 |
Bitewings - two radiographic images |
778 |
775 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
503 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
36 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
39 |
38 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
28 |
$4K |
| D1330 |
|
15 |
15 |
$85.75 |
| D0601 |
|
597 |
592 |
$0.00 |
| D0603 |
|
1,401 |
1,389 |
$0.00 |
| D0602 |
|
936 |
932 |
$0.00 |