| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,063 |
179 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
413 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,163 |
704 |
$10K |
| D1120 |
Prophylaxis - child |
543 |
495 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,303 |
424 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
740 |
679 |
$6K |
| D0274 |
Bitewings - four radiographic images |
223 |
208 |
$6K |
| D1110 |
Prophylaxis - adult |
170 |
158 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,390 |
621 |
$5K |
| D2332 |
|
534 |
204 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
703 |
637 |
$3K |
| D2330 |
|
1,182 |
410 |
$3K |
| D0272 |
Bitewings - two radiographic images |
196 |
171 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
193 |
$2K |
| D2331 |
|
484 |
209 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
54 |
46 |
$1K |
| D0603 |
|
769 |
703 |
$0.00 |