| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,608 |
696 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,665 |
2,530 |
$71K |
| D1120 |
Prophylaxis - child |
1,827 |
1,750 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,518 |
2,752 |
$56K |
| D1110 |
Prophylaxis - adult |
1,101 |
1,021 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
546 |
218 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,460 |
2,336 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,956 |
2,785 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,105 |
1,024 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,055 |
1,020 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
170 |
168 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
17 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
78 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
30 |
$441.00 |
| D0603 |
|
3,865 |
3,466 |
$0.00 |
| D1999 |
|
141 |
122 |
$0.00 |
| D9986 |
|
22 |
19 |
$0.00 |