| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,076 |
191 |
$23K |
| D1120 |
Prophylaxis - child |
551 |
484 |
$22K |
| D1206 |
Topical application of fluoride varnish |
672 |
609 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
449 |
402 |
$13K |
| D0274 |
Bitewings - four radiographic images |
488 |
435 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
137 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
247 |
$8K |
| D4355 |
|
106 |
90 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,005 |
669 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
253 |
213 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
334 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
39 |
$3K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$874.24 |