| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,617 |
278 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,139 |
1,082 |
$30K |
| D1120 |
Prophylaxis - child |
816 |
775 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,131 |
1,394 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
136 |
$26K |
| D1110 |
Prophylaxis - adult |
440 |
410 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,475 |
1,395 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
116 |
105 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,539 |
1,420 |
$14K |
| D0274 |
Bitewings - four radiographic images |
527 |
489 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
106 |
$4K |
| D0272 |
Bitewings - two radiographic images |
180 |
167 |
$3K |
| D0330 |
Panoramic radiographic image |
76 |
67 |
$1K |
| D0603 |
|
1,922 |
1,823 |
$0.00 |