| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
765 |
119 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
362 |
342 |
$9K |
| D1120 |
Prophylaxis - child |
245 |
234 |
$8K |
| D1110 |
Prophylaxis - adult |
159 |
149 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
418 |
393 |
$5K |
| D0274 |
Bitewings - four radiographic images |
191 |
173 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
424 |
395 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
409 |
373 |
$4K |
| D0272 |
Bitewings - two radiographic images |
180 |
176 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$578.07 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
14 |
$441.51 |
| D0603 |
|
347 |
346 |
$0.00 |
| D0602 |
|
73 |
73 |
$0.00 |