| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,640 |
1,232 |
$151K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,495 |
787 |
$148K |
| D0145 |
Oral evaluation for a patient under three years of age |
929 |
925 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
4,180 |
4,160 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,524 |
836 |
$117K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,173 |
4,158 |
$105K |
| D1120 |
Prophylaxis - child |
2,646 |
2,623 |
$94K |
| D1110 |
Prophylaxis - adult |
1,598 |
1,595 |
$86K |
| D0272 |
Bitewings - two radiographic images |
3,188 |
3,175 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,487 |
4,460 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
4,199 |
4,178 |
$52K |
| D0274 |
Bitewings - four radiographic images |
562 |
558 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$879.47 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$225.36 |
| D0602 |
|
5,536 |
5,457 |
$0.00 |
| D0601 |
|
64 |
64 |
$0.00 |
| D0603 |
|
26 |
24 |
$0.00 |