| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,813 |
723 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,909 |
1,876 |
$52K |
| D0145 |
Oral evaluation for a patient under three years of age |
357 |
354 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
660 |
198 |
$47K |
| D1120 |
Prophylaxis - child |
1,076 |
1,055 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,289 |
2,241 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
136 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,255 |
2,208 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,260 |
2,126 |
$21K |
| D0274 |
Bitewings - four radiographic images |
724 |
709 |
$17K |
| D1110 |
Prophylaxis - adult |
303 |
296 |
$15K |
| D0272 |
Bitewings - two radiographic images |
545 |
534 |
$12K |
| D0330 |
Panoramic radiographic image |
196 |
193 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$187.80 |
| D0601 |
|
1,236 |
1,211 |
$0.01 |
| D0603 |
|
239 |
234 |
$0.00 |
| D0602 |
|
499 |
489 |
$0.00 |