| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,956 |
1,045 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
885 |
558 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,138 |
681 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,133 |
2,093 |
$59K |
| D1110 |
Prophylaxis - adult |
1,099 |
1,086 |
$58K |
| D1120 |
Prophylaxis - child |
1,472 |
1,444 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,670 |
2,632 |
$38K |
| D0274 |
Bitewings - four radiographic images |
814 |
810 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,474 |
1,154 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
298 |
288 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
135 |
135 |
$19K |
| D0272 |
Bitewings - two radiographic images |
766 |
753 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,298 |
1,277 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
433 |
$15K |
| D0602 |
|
798 |
788 |
$0.00 |
| D0603 |
|
2,133 |
2,098 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |