| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
472 |
147 |
$12K |
| D1120 |
Prophylaxis - child |
395 |
383 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
214 |
$10K |
| D0330 |
Panoramic radiographic image |
140 |
133 |
$6K |
| D1206 |
Topical application of fluoride varnish |
362 |
346 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
182 |
$4K |
| D0272 |
Bitewings - two radiographic images |
263 |
255 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
195 |
185 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
180 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
74 |
$1K |
| D1354 |
|
54 |
13 |
$269.50 |
| D1330 |
|
344 |
329 |
$0.00 |
| D1310 |
|
338 |
322 |
$0.00 |
| D0603 |
|
195 |
186 |
$0.00 |