| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,343 |
160 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
317 |
305 |
$9K |
| D1110 |
Prophylaxis - adult |
159 |
154 |
$8K |
| D1120 |
Prophylaxis - child |
223 |
215 |
$8K |
| D0274 |
Bitewings - four radiographic images |
240 |
232 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
389 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
384 |
369 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
361 |
349 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
12 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
43 |
$1K |
| D0601 |
|
362 |
360 |
$0.00 |
| D0603 |
|
14 |
14 |
$0.00 |