| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,692 |
878 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
1,591 |
1,504 |
$42K |
| D1120 |
Prophylaxis - child |
1,238 |
1,138 |
$40K |
| D0145 |
Oral evaluation for a patient under three years of age |
306 |
282 |
$39K |
| D1110 |
Prophylaxis - adult |
731 |
679 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,121 |
1,026 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,007 |
1,856 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,000 |
1,827 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,929 |
1,767 |
$18K |
| D0272 |
Bitewings - two radiographic images |
549 |
512 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
41 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
139 |
$4K |
| D0330 |
Panoramic radiographic image |
32 |
28 |
$825.72 |
| D0603 |
|
2,531 |
2,355 |
$0.00 |