| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
639 |
127 |
$16K |
| D1120 |
Prophylaxis - child |
451 |
438 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
65 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
954 |
444 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
381 |
369 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
699 |
672 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
491 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
166 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
41 |
$5K |
| D1110 |
Prophylaxis - adult |
86 |
82 |
$4K |
| D0274 |
Bitewings - four radiographic images |
99 |
98 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
46 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
12 |
$2K |
| D0603 |
|
362 |
347 |
$9.01 |
| D0602 |
|
222 |
217 |
$0.00 |