| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,485 |
299 |
$13K |
| D1120 |
Prophylaxis - child |
421 |
412 |
$5K |
| D1206 |
Topical application of fluoride varnish |
795 |
770 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
186 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
124 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
155 |
$2K |
| D0272 |
Bitewings - two radiographic images |
166 |
162 |
$1K |
| D1354 |
|
100 |
26 |
$669.69 |
| D9999 |
Unspecified adjunctive procedure, by report |
21 |
21 |
$525.00 |
| D0274 |
Bitewings - four radiographic images |
104 |
97 |
$472.01 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$452.00 |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
248 |
$268.90 |
| D1330 |
|
103 |
103 |
$12.00 |