| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,610 |
736 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,050 |
592 |
$102K |
| D1120 |
Prophylaxis - child |
2,393 |
2,350 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
3,024 |
2,976 |
$83K |
| D0145 |
Oral evaluation for a patient under three years of age |
569 |
563 |
$78K |
| D1110 |
Prophylaxis - adult |
1,476 |
1,456 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,550 |
3,145 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,862 |
3,801 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,403 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
625 |
616 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,375 |
3,318 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
949 |
934 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
249 |
$25K |
| D0272 |
Bitewings - two radiographic images |
866 |
855 |
$19K |
| D0330 |
Panoramic radiographic image |
19 |
15 |
$87.42 |
| D0603 |
|
3,958 |
3,900 |
$5.00 |
| D0601 |
|
89 |
86 |
$0.00 |
| D0602 |
|
499 |
496 |
$0.00 |