| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,590 |
451 |
$87K |
| D1110 |
Prophylaxis - adult |
1,167 |
1,105 |
$58K |
| D1120 |
Prophylaxis - child |
1,478 |
1,452 |
$51K |
| D0145 |
Oral evaluation for a patient under three years of age |
384 |
371 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,746 |
1,691 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,317 |
2,244 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,140 |
1,079 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,562 |
2,436 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,126 |
2,066 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
739 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,003 |
988 |
$23K |
| D0330 |
Panoramic radiographic image |
177 |
172 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
41 |
$6K |
| D1206 |
Topical application of fluoride varnish |
329 |
312 |
$4K |
| D0603 |
|
3,868 |
3,729 |
$785.03 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$478.14 |