| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,898 |
871 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
2,905 |
2,789 |
$68K |
| D1110 |
Prophylaxis - adult |
1,323 |
1,273 |
$56K |
| D1120 |
Prophylaxis - child |
1,903 |
1,856 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
460 |
439 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,585 |
1,525 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,723 |
2,709 |
$41K |
| D1206 |
Topical application of fluoride varnish |
3,189 |
3,077 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,002 |
2,869 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
272 |
266 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
108 |
$15K |
| D0272 |
Bitewings - two radiographic images |
652 |
629 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
145 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
36 |
$3K |
| D0603 |
|
1,403 |
1,377 |
$9.00 |
| D0601 |
|
1,702 |
1,669 |
$0.02 |
| D0602 |
|
620 |
605 |
$0.00 |