| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,304 |
242 |
$14K |
| D1110 |
Prophylaxis - adult |
302 |
298 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
477 |
472 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
88 |
$7K |
| D0274 |
Bitewings - four radiographic images |
334 |
327 |
$6K |
| D1120 |
Prophylaxis - child |
288 |
284 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
583 |
576 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
45 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
457 |
452 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
446 |
426 |
$3K |
| D0272 |
Bitewings - two radiographic images |
190 |
187 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
64 |
$1K |
| D0330 |
Panoramic radiographic image |
60 |
57 |
$661.22 |
| D0603 |
|
333 |
329 |
$0.00 |
| D0601 |
|
58 |
58 |
$0.00 |
| D0602 |
|
276 |
273 |
$0.00 |