| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
258 |
151 |
$19K |
| D4342 |
|
92 |
56 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
556 |
547 |
$16K |
| D1120 |
Prophylaxis - child |
379 |
376 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
409 |
409 |
$11K |
| D0274 |
Bitewings - four radiographic images |
369 |
367 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
46 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
758 |
746 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
621 |
616 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
120 |
$3K |
| D4910 |
|
33 |
33 |
$2K |
| D9110 |
|
24 |
23 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
21 |
$624.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$492.00 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$465.78 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$451.50 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$245.64 |