| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,652 |
293 |
$42K |
| D1120 |
Prophylaxis - child |
596 |
574 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
37 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
602 |
580 |
$16K |
| D0272 |
Bitewings - two radiographic images |
471 |
458 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
750 |
727 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
128 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
28 |
$9K |
| D1110 |
Prophylaxis - adult |
150 |
148 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
640 |
620 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
639 |
595 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
28 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
31 |
31 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
107 |
$4K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$338.04 |
| D0603 |
|
439 |
424 |
$0.00 |
| D0601 |
|
304 |
295 |
$0.00 |
| D0602 |
|
73 |
70 |
$0.00 |