| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,195 |
307 |
$55K |
| D1110 |
Prophylaxis - adult |
886 |
882 |
$32K |
| D1120 |
Prophylaxis - child |
918 |
913 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,248 |
1,240 |
$25K |
| D0274 |
Bitewings - four radiographic images |
557 |
553 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
616 |
612 |
$13K |
| D1206 |
Topical application of fluoride varnish |
609 |
603 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
581 |
581 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
94 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
104 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
126 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
579 |
563 |
$5K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
490 |
439 |
$4K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$259.15 |