| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
456 |
84 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
360 |
$10K |
| D1120 |
Prophylaxis - child |
263 |
250 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
820 |
291 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
516 |
489 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
309 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
17 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
40 |
$2K |
| D0272 |
Bitewings - two radiographic images |
63 |
59 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
21 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
25 |
$880.16 |
| D0274 |
Bitewings - four radiographic images |
18 |
17 |
$553.76 |
| D0601 |
|
90 |
88 |
$0.00 |
| D0603 |
|
282 |
267 |
$0.00 |
| D0602 |
|
72 |
64 |
$0.00 |