| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,496 |
1,038 |
$195K |
| D0120 |
Periodic oral evaluation - established patient |
3,939 |
3,891 |
$110K |
| D1120 |
Prophylaxis - child |
2,698 |
2,673 |
$96K |
| D1110 |
Prophylaxis - adult |
1,659 |
1,636 |
$87K |
| D0145 |
Oral evaluation for a patient under three years of age |
593 |
585 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,368 |
4,317 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
745 |
324 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,043 |
1,029 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,719 |
2,665 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,469 |
2,423 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,047 |
1,040 |
$21K |
| D0330 |
Panoramic radiographic image |
796 |
784 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
83 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
194 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$5K |
| D0603 |
|
5,111 |
5,061 |
$0.00 |
| D0602 |
|
17 |
16 |
$0.00 |
| D9986 |
|
44 |
42 |
$0.00 |