| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,907 |
303 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
467 |
204 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,505 |
1,124 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,136 |
1,079 |
$21K |
| D1110 |
Prophylaxis - adult |
586 |
563 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,329 |
1,272 |
$21K |
| D1120 |
Prophylaxis - child |
629 |
613 |
$17K |
| D0274 |
Bitewings - four radiographic images |
617 |
584 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,267 |
1,195 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
102 |
$12K |
| D0272 |
Bitewings - two radiographic images |
379 |
369 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
75 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
52 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$725.00 |