| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,741 |
921 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
2,474 |
2,417 |
$68K |
| D1120 |
Prophylaxis - child |
1,426 |
1,399 |
$50K |
| D1110 |
Prophylaxis - adult |
842 |
829 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,097 |
3,040 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,671 |
1,628 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,037 |
2,973 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,975 |
2,842 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
284 |
106 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
80 |
$14K |
| D0272 |
Bitewings - two radiographic images |
258 |
254 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
25 |
$4K |
| D0330 |
Panoramic radiographic image |
336 |
331 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D9248 |
|
14 |
14 |
$731.28 |
| D0603 |
|
521 |
514 |
$0.04 |
| D0602 |
|
1,534 |
1,479 |
$0.02 |
| D0601 |
|
484 |
477 |
$0.00 |