| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
506 |
281 |
$41K |
| D4341 |
|
165 |
90 |
$35K |
| D1120 |
Prophylaxis - child |
767 |
690 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
793 |
718 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
522 |
460 |
$13K |
| D0274 |
Bitewings - four radiographic images |
605 |
564 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
341 |
$7K |
| D1206 |
Topical application of fluoride varnish |
216 |
203 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
879 |
812 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
55 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
842 |
753 |
$3K |
| D4355 |
|
92 |
81 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
33 |
$2K |
| D0272 |
Bitewings - two radiographic images |
154 |
135 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
54 |
$810.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$37.70 |