| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
15,683 |
5,259 |
$366K |
| D1120 |
Prophylaxis - child |
9,024 |
9,015 |
$286K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,229 |
6,223 |
$216K |
| D0272 |
Bitewings - two radiographic images |
7,185 |
7,181 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
5,973 |
5,969 |
$139K |
| D0274 |
Bitewings - four radiographic images |
3,727 |
3,725 |
$110K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,555 |
5,549 |
$99K |
| D0220 |
Intraoral - periapical first radiographic image |
8,089 |
8,073 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,959 |
7,909 |
$74K |
| D1206 |
Topical application of fluoride varnish |
3,688 |
3,686 |
$70K |
| D0140 |
Limited oral evaluation - problem focused |
276 |
272 |
$8K |
| D4346 |
|
68 |
68 |
$7K |
| D0240 |
|
220 |
160 |
$4K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$954.89 |