| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,239 |
1,204 |
$141K |
| D0274 |
Bitewings - four radiographic images |
6,087 |
5,964 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
6,330 |
6,217 |
$108K |
| D1110 |
Prophylaxis - adult |
3,031 |
2,970 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,186 |
6,076 |
$89K |
| D1120 |
Prophylaxis - child |
2,825 |
2,788 |
$66K |
| D0330 |
Panoramic radiographic image |
1,358 |
1,310 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,037 |
635 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,130 |
1,105 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
453 |
298 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,768 |
1,722 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,948 |
960 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
137 |
108 |
$9K |
| D4355 |
|
125 |
121 |
$9K |
| D9110 |
|
146 |
134 |
$3K |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$761.31 |
| D1999 |
|
2,045 |
1,820 |
$0.00 |