| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,924 |
771 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
570 |
258 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,301 |
1,293 |
$37K |
| D1120 |
Prophylaxis - child |
1,011 |
1,000 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,216 |
1,572 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,566 |
1,554 |
$22K |
| D1110 |
Prophylaxis - adult |
399 |
398 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,661 |
1,639 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
134 |
$15K |
| D0274 |
Bitewings - four radiographic images |
453 |
450 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
79 |
78 |
$11K |
| D0272 |
Bitewings - two radiographic images |
356 |
355 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
92 |
$3K |
| D0603 |
|
1,975 |
1,959 |
$0.00 |