| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,131 |
390 |
$57K |
| D1120 |
Prophylaxis - child |
1,266 |
1,265 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,581 |
1,579 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
461 |
169 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,727 |
1,726 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,600 |
1,590 |
$20K |
| D0274 |
Bitewings - four radiographic images |
570 |
570 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,600 |
1,584 |
$18K |
| D1110 |
Prophylaxis - adult |
185 |
185 |
$10K |
| D0272 |
Bitewings - two radiographic images |
409 |
409 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$314.16 |
| D0603 |
|
406 |
404 |
$0.00 |
| D0602 |
|
1,416 |
1,413 |
$0.00 |