| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,918 |
560 |
$95K |
| D1110 |
Prophylaxis - adult |
1,536 |
1,499 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,850 |
2,796 |
$79K |
| D0274 |
Bitewings - four radiographic images |
1,592 |
1,557 |
$53K |
| D1120 |
Prophylaxis - child |
1,429 |
1,408 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,955 |
2,906 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,165 |
2,123 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,093 |
2,018 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,315 |
1,288 |
$21K |
| D0330 |
Panoramic radiographic image |
344 |
334 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$7K |
| D0350 |
|
57 |
55 |
$919.00 |
| D0601 |
|
1,069 |
1,054 |
$0.00 |
| D0602 |
|
2,072 |
2,058 |
$0.00 |