| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,785 |
729 |
$68K |
| D0145 |
Oral evaluation for a patient under three years of age |
386 |
383 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,801 |
1,784 |
$51K |
| D1120 |
Prophylaxis - child |
1,376 |
1,366 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,883 |
1,865 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
114 |
$27K |
| D0274 |
Bitewings - four radiographic images |
596 |
595 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,627 |
1,602 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,523 |
1,510 |
$17K |
| D0272 |
Bitewings - two radiographic images |
657 |
654 |
$15K |
| D1110 |
Prophylaxis - adult |
245 |
244 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0603 |
|
2,807 |
2,621 |
$0.00 |