| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
907 |
180 |
$24K |
| D1120 |
Prophylaxis - child |
350 |
338 |
$12K |
| D1110 |
Prophylaxis - adult |
207 |
202 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
296 |
291 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
55 |
$10K |
| D0274 |
Bitewings - four radiographic images |
306 |
295 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
552 |
534 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
242 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
41 |
39 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
454 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
453 |
432 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
32 |
$4K |
| D0272 |
Bitewings - two radiographic images |
125 |
119 |
$3K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$707.73 |
| D0603 |
|
705 |
622 |
$0.00 |
| D0601 |
|
39 |
38 |
$0.00 |