| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
139 |
136 |
$7K |
| D1351 |
Sealant - per tooth |
278 |
28 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
28 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
31 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
142 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
198 |
$3K |
| D1120 |
Prophylaxis - child |
65 |
63 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
45 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
81 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$861.22 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$296.92 |
| D0602 |
|
39 |
38 |
$0.00 |
| D0603 |
|
132 |
130 |
$0.00 |
| D0601 |
|
43 |
41 |
$0.00 |