| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,311 |
784 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
809 |
302 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,843 |
1,799 |
$51K |
| D1110 |
Prophylaxis - adult |
774 |
756 |
$41K |
| D1120 |
Prophylaxis - child |
1,050 |
1,025 |
$37K |
| D0274 |
Bitewings - four radiographic images |
872 |
848 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,914 |
1,871 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,598 |
1,527 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,702 |
1,515 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
225 |
222 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
95 |
92 |
$13K |
| D0272 |
Bitewings - two radiographic images |
401 |
392 |
$9K |
| D0602 |
|
378 |
377 |
$0.00 |
| D0603 |
|
1,635 |
1,617 |
$0.00 |