| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,040 |
733 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
2,224 |
2,205 |
$60K |
| D1110 |
Prophylaxis - adult |
799 |
794 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,916 |
2,893 |
$39K |
| D1120 |
Prophylaxis - child |
1,093 |
1,083 |
$36K |
| D0330 |
Panoramic radiographic image |
1,354 |
1,344 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
250 |
42 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,430 |
1,408 |
$13K |
| D0272 |
Bitewings - two radiographic images |
746 |
740 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,340 |
1,158 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
31 |
$10K |
| D0274 |
Bitewings - four radiographic images |
447 |
445 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
159 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$3K |
| D0603 |
|
1,658 |
1,644 |
$0.06 |
| D0601 |
|
415 |
412 |
$0.00 |
| D0602 |
|
397 |
390 |
$0.00 |