| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,004 |
124 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
363 |
202 |
$18K |
| D1110 |
Prophylaxis - adult |
311 |
307 |
$8K |
| D1120 |
Prophylaxis - child |
259 |
253 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
299 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
170 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
69 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
80 |
$6K |
| D1206 |
Topical application of fluoride varnish |
387 |
380 |
$6K |
| D4355 |
|
87 |
86 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
218 |
$5K |
| D0274 |
Bitewings - four radiographic images |
277 |
274 |
$4K |
| D4341 |
|
74 |
28 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
921 |
404 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
136 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
436 |
$2K |
| D2950 |
|
20 |
15 |
$1K |
| D0602 |
|
136 |
133 |
$1K |
| D0603 |
|
89 |
87 |
$860.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$262.50 |
| D0601 |
|
12 |
12 |
$120.00 |