| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,873 |
1,241 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
2,834 |
2,806 |
$78K |
| D1120 |
Prophylaxis - child |
1,970 |
1,943 |
$69K |
| D1110 |
Prophylaxis - adult |
1,229 |
1,214 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,208 |
3,171 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
447 |
436 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
102 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
73 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
535 |
517 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
154 |
$5K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$2K |
| D1999 |
|
283 |
278 |
$5.00 |
| D0601 |
|
866 |
853 |
$0.00 |
| D0602 |
|
963 |
945 |
$0.00 |
| D0603 |
|
1,327 |
1,309 |
$0.00 |