| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,585 |
572 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,941 |
1,929 |
$54K |
| D1120 |
Prophylaxis - child |
1,245 |
1,239 |
$44K |
| D1110 |
Prophylaxis - adult |
801 |
794 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,913 |
1,834 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,065 |
1,057 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,073 |
2,059 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,041 |
2,003 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
57 |
$10K |
| D0330 |
Panoramic radiographic image |
223 |
221 |
$5K |
| D0272 |
Bitewings - two radiographic images |
199 |
199 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0602 |
|
2,132 |
2,110 |
$0.00 |
| D0603 |
|
182 |
182 |
$0.00 |