| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,815 |
507 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,333 |
2,292 |
$63K |
| D1120 |
Prophylaxis - child |
1,728 |
1,699 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
507 |
229 |
$47K |
| D1110 |
Prophylaxis - adult |
912 |
896 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,320 |
1,289 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,465 |
2,424 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,792 |
2,228 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,487 |
2,420 |
$29K |
| D0145 |
Oral evaluation for a patient under three years of age |
81 |
80 |
$11K |
| D0272 |
Bitewings - two radiographic images |
460 |
452 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
283 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$835.12 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$803.32 |
| D0160 |
|
14 |
13 |
$194.35 |
| D0350 |
|
13 |
13 |
$183.80 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$160.23 |
| D1330 |
|
12 |
12 |
$147.25 |
| D0601 |
|
1,429 |
1,407 |
$60.02 |
| D0603 |
|
1,272 |
1,245 |
$9.14 |
| D0602 |
|
256 |
254 |
$0.00 |