| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,649 |
181 |
$31K |
| D1120 |
Prophylaxis - child |
298 |
275 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
216 |
192 |
$11K |
| D1206 |
Topical application of fluoride varnish |
333 |
305 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
270 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
268 |
229 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
32 |
$4K |
| D0274 |
Bitewings - four radiographic images |
177 |
160 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
250 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
44 |
$2K |
| D1110 |
Prophylaxis - adult |
64 |
47 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
16 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
172 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
63 |
$575.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
12 |
$122.88 |
| D1330 |
|
46 |
43 |
$0.00 |