| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,775 |
1,108 |
$127K |
| D1110 |
Prophylaxis - adult |
1,736 |
1,718 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,175 |
3,142 |
$89K |
| D0274 |
Bitewings - four radiographic images |
2,613 |
2,588 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,396 |
3,127 |
$59K |
| D1120 |
Prophylaxis - child |
1,625 |
1,608 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
284 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,333 |
3,299 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
3,260 |
3,211 |
$39K |
| D0145 |
Oral evaluation for a patient under three years of age |
140 |
134 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
138 |
$14K |
| D0272 |
Bitewings - two radiographic images |
301 |
298 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
519 |
469 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$883.00 |
| D9215 |
|
321 |
292 |
$20.00 |
| D0603 |
|
2,879 |
2,854 |
$0.04 |
| D0602 |
|
889 |
881 |
$0.00 |