| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,147 |
420 |
$58K |
| D1120 |
Prophylaxis - child |
1,466 |
1,457 |
$52K |
| D1110 |
Prophylaxis - adult |
864 |
858 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,189 |
1,179 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,398 |
2,380 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,196 |
1,186 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,294 |
1,279 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
114 |
113 |
$16K |
| D0272 |
Bitewings - two radiographic images |
529 |
526 |
$12K |
| D0330 |
Panoramic radiographic image |
153 |
153 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
633 |
586 |
$7K |
| D0603 |
|
1,959 |
1,921 |
$0.00 |
| D0601 |
|
24 |
24 |
$0.00 |