| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,641 |
308 |
$42K |
| D1110 |
Prophylaxis - adult |
592 |
567 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
937 |
904 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,239 |
1,198 |
$17K |
| D0274 |
Bitewings - four radiographic images |
518 |
497 |
$17K |
| D1120 |
Prophylaxis - child |
427 |
416 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
54 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
139 |
134 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
630 |
593 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
221 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
607 |
575 |
$6K |
| D0350 |
|
86 |
81 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$327.32 |
| D0602 |
|
655 |
634 |
$0.00 |
| D0603 |
|
334 |
318 |
$0.00 |
| D0601 |
|
17 |
17 |
$0.00 |