| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
688 |
108 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
214 |
$12K |
| D1206 |
Topical application of fluoride varnish |
262 |
238 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,583 |
490 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
448 |
434 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
264 |
249 |
$8K |
| D1120 |
Prophylaxis - child |
171 |
158 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
579 |
555 |
$8K |
| D0274 |
Bitewings - four radiographic images |
329 |
313 |
$7K |
| D0330 |
Panoramic radiographic image |
176 |
167 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
106 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
90 |
88 |
$2K |
| D4355 |
|
51 |
39 |
$1K |
| D4346 |
|
49 |
41 |
$742.00 |
| D0272 |
Bitewings - two radiographic images |
39 |
38 |
$659.76 |