| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
570 |
102 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
45 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,544 |
617 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
192 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
678 |
662 |
$6K |
| D1110 |
Prophylaxis - adult |
117 |
116 |
$6K |
| D0274 |
Bitewings - four radiographic images |
188 |
186 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
200 |
193 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
399 |
396 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
18 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$2K |
| D0330 |
Panoramic radiographic image |
82 |
82 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$1K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$844.16 |
| D0603 |
|
814 |
802 |
$0.00 |