| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,379 |
239 |
$32K |
| D1110 |
Prophylaxis - adult |
755 |
701 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,011 |
939 |
$20K |
| D0274 |
Bitewings - four radiographic images |
830 |
774 |
$18K |
| D1120 |
Prophylaxis - child |
557 |
522 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,381 |
1,034 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,194 |
1,115 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
448 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
398 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
67 |
$7K |
| D1206 |
Topical application of fluoride varnish |
287 |
287 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
117 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
40 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
97 |
97 |
$4K |
| D0272 |
Bitewings - two radiographic images |
245 |
230 |
$3K |
| D0270 |
|
28 |
27 |
$218.40 |