| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
879 |
76 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
166 |
93 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
751 |
381 |
$5K |
| D0274 |
Bitewings - four radiographic images |
503 |
253 |
$4K |
| D1110 |
Prophylaxis - adult |
321 |
164 |
$4K |
| D1120 |
Prophylaxis - child |
361 |
182 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
778 |
396 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
382 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
811 |
381 |
$2K |
| D0350 |
|
181 |
92 |
$790.34 |
| D0272 |
Bitewings - two radiographic images |
102 |
48 |
$619.57 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
13 |
$229.58 |
| D0601 |
|
575 |
300 |
$0.00 |
| D0603 |
|
81 |
35 |
$0.00 |
| D0602 |
|
216 |
113 |
$0.00 |