| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,160 |
1,075 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
2,129 |
2,064 |
$56K |
| D1120 |
Prophylaxis - child |
1,581 |
1,537 |
$53K |
| D1110 |
Prophylaxis - adult |
781 |
759 |
$39K |
| D1206 |
Topical application of fluoride varnish |
2,658 |
2,589 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,089 |
1,054 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,153 |
1,119 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,152 |
2,058 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,343 |
1,956 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
315 |
309 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
69 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
27 |
$7K |
| D0330 |
Panoramic radiographic image |
262 |
255 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$882.00 |
| D0602 |
|
1,484 |
1,453 |
$0.00 |
| D0603 |
|
748 |
731 |
$0.00 |
| D0601 |
|
356 |
351 |
$0.00 |