| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,444 |
224 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
412 |
$9K |
| D1120 |
Prophylaxis - child |
358 |
302 |
$9K |
| D1206 |
Topical application of fluoride varnish |
525 |
432 |
$5K |
| D0272 |
Bitewings - two radiographic images |
311 |
258 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
576 |
473 |
$5K |
| D1110 |
Prophylaxis - adult |
140 |
113 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
572 |
457 |
$4K |
| D0274 |
Bitewings - four radiographic images |
196 |
164 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
64 |
$1K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$737.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
75 |
$441.00 |
| D0602 |
|
406 |
338 |
$0.00 |
| D0601 |
|
78 |
78 |
$0.00 |
| D0603 |
|
89 |
62 |
$0.00 |