| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,499 |
934 |
$149K |
| D1120 |
Prophylaxis - child |
2,397 |
2,397 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,695 |
2,695 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,385 |
2,385 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
402 |
$40K |
| D4341 |
|
170 |
99 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,437 |
1,437 |
$28K |
| D1110 |
Prophylaxis - adult |
462 |
462 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
687 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,200 |
2,186 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
261 |
236 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,859 |
1,857 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
297 |
295 |
$6K |
| D0272 |
Bitewings - two radiographic images |
499 |
499 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
151 |
$2K |
| D4910 |
|
12 |
12 |
$804.00 |
| D0270 |
|
47 |
47 |
$257.61 |