| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,184 |
1,489 |
$222K |
| D1120 |
Prophylaxis - child |
5,162 |
4,890 |
$212K |
| D0120 |
Periodic oral evaluation - established patient |
5,189 |
4,907 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,154 |
4,883 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,249 |
1,022 |
$131K |
| D2335 |
|
147 |
135 |
$21K |
| D2332 |
|
150 |
143 |
$16K |
| D0272 |
Bitewings - two radiographic images |
994 |
901 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
55 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$2K |
| D9110 |
|
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
123 |
$810.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$62.72 |
| D1999 |
|
376 |
328 |
$0.00 |