| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,785 |
1,053 |
$146K |
| D1120 |
Prophylaxis - child |
1,936 |
1,873 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,076 |
2,011 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,387 |
3,081 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
531 |
279 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,108 |
3,009 |
$43K |
| D1110 |
Prophylaxis - adult |
708 |
681 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,325 |
3,207 |
$37K |
| D0274 |
Bitewings - four radiographic images |
901 |
868 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
677 |
655 |
$23K |
| D0272 |
Bitewings - two radiographic images |
883 |
858 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
67 |
67 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
27 |
$3K |
| D0240 |
|
15 |
15 |
$117.60 |
| D0603 |
|
3,845 |
3,702 |
$40.02 |