| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,352 |
927 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
2,435 |
2,336 |
$64K |
| D1120 |
Prophylaxis - child |
1,644 |
1,579 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
322 |
316 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,701 |
2,595 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,752 |
2,639 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,067 |
2,524 |
$31K |
| D1110 |
Prophylaxis - adult |
539 |
520 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,043 |
994 |
$22K |
| D0274 |
Bitewings - four radiographic images |
646 |
626 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$847.68 |
| D0603 |
|
3,701 |
3,610 |
$0.00 |