| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,490 |
668 |
$85K |
| D1110 |
Prophylaxis - adult |
1,642 |
1,642 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,540 |
1,539 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,786 |
1,786 |
$35K |
| D1120 |
Prophylaxis - child |
1,286 |
1,285 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,673 |
1,671 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,402 |
1,399 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
469 |
286 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
248 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,352 |
1,166 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,249 |
1,247 |
$10K |
| D0272 |
Bitewings - two radiographic images |
400 |
400 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
29 |
$2K |
| D1206 |
Topical application of fluoride varnish |
69 |
69 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$519.80 |
| D1999 |
|
87 |
84 |
$0.00 |