| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,623 |
540 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,305 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
226 |
$36K |
| D1120 |
Prophylaxis - child |
991 |
978 |
$34K |
| D0145 |
Oral evaluation for a patient under three years of age |
250 |
248 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
159 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,419 |
1,397 |
$20K |
| D1110 |
Prophylaxis - adult |
363 |
357 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,572 |
1,260 |
$17K |
| D0274 |
Bitewings - four radiographic images |
517 |
507 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,300 |
1,275 |
$16K |
| D0272 |
Bitewings - two radiographic images |
586 |
578 |
$13K |
| D0602 |
|
1,724 |
1,661 |
$0.00 |