| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,651 |
1,645 |
$170K |
| D1120 |
Prophylaxis - child |
4,834 |
4,834 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,852 |
2,852 |
$116K |
| D1206 |
Topical application of fluoride varnish |
6,972 |
6,972 |
$115K |
| D1110 |
Prophylaxis - adult |
1,849 |
1,849 |
$93K |
| D0274 |
Bitewings - four radiographic images |
2,261 |
2,261 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,241 |
2,241 |
$52K |
| D0272 |
Bitewings - two radiographic images |
1,383 |
1,383 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,072 |
1,068 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
90 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,086 |
550 |
$10K |
| D0240 |
|
436 |
238 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
107 |
107 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
101 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$960.36 |