| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,839 |
228 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
480 |
$16K |
| D1110 |
Prophylaxis - adult |
312 |
311 |
$16K |
| D1120 |
Prophylaxis - child |
460 |
453 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
961 |
952 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,504 |
946 |
$13K |
| D0274 |
Bitewings - four radiographic images |
495 |
492 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
1,021 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
343 |
$10K |
| D0330 |
Panoramic radiographic image |
408 |
403 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
51 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
26 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$187.80 |
| D0603 |
|
1,342 |
1,328 |
$0.00 |