| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,547 |
322 |
$41K |
| D1120 |
Prophylaxis - child |
881 |
874 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,033 |
1,022 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
123 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,468 |
1,457 |
$21K |
| D1110 |
Prophylaxis - adult |
341 |
338 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,120 |
1,104 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,094 |
1,078 |
$12K |
| D0272 |
Bitewings - two radiographic images |
400 |
397 |
$9K |
| D0274 |
Bitewings - four radiographic images |
251 |
248 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
179 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0603 |
|
1,862 |
1,840 |
$0.00 |