| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,153 |
694 |
$106K |
| D1120 |
Prophylaxis - child |
1,667 |
1,667 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,911 |
1,911 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,648 |
1,648 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
273 |
$25K |
| D4341 |
|
137 |
84 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
1,044 |
$20K |
| D1110 |
Prophylaxis - adult |
303 |
303 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
492 |
492 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
188 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,377 |
1,371 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,177 |
1,176 |
$8K |
| D0272 |
Bitewings - two radiographic images |
345 |
345 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
141 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
61 |
$729.65 |