| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,208 |
227 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,040 |
1,032 |
$29K |
| D1110 |
Prophylaxis - adult |
539 |
537 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
140 |
$26K |
| D1120 |
Prophylaxis - child |
625 |
620 |
$22K |
| D0274 |
Bitewings - four radiographic images |
809 |
804 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,658 |
800 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,428 |
1,418 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
981 |
938 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
50 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
203 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$918.32 |
| D0330 |
Panoramic radiographic image |
49 |
48 |
$459.38 |
| D0601 |
|
357 |
354 |
$0.00 |
| D0603 |
|
721 |
716 |
$0.00 |
| D0602 |
|
418 |
413 |
$0.00 |