| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,588 |
286 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
176 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
733 |
656 |
$12K |
| D0274 |
Bitewings - four radiographic images |
709 |
632 |
$10K |
| D1120 |
Prophylaxis - child |
486 |
443 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,398 |
1,231 |
$9K |
| D1110 |
Prophylaxis - adult |
401 |
357 |
$9K |
| D1206 |
Topical application of fluoride varnish |
738 |
658 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,808 |
1,084 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
510 |
438 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
255 |
243 |
$4K |
| D0330 |
Panoramic radiographic image |
128 |
112 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
41 |
$3K |
| D0272 |
Bitewings - two radiographic images |
200 |
187 |
$2K |
| D4346 |
|
13 |
13 |
$848.86 |
| D1999 |
|
883 |
745 |
$0.00 |