| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,383 |
506 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,987 |
1,762 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
287 |
$41K |
| D1120 |
Prophylaxis - child |
1,258 |
1,142 |
$39K |
| D1110 |
Prophylaxis - adult |
828 |
748 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
665 |
292 |
$35K |
| D1206 |
Topical application of fluoride varnish |
2,084 |
1,905 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,817 |
1,940 |
$25K |
| D0274 |
Bitewings - four radiographic images |
955 |
859 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,277 |
2,017 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
123 |
119 |
$15K |
| D0272 |
Bitewings - two radiographic images |
704 |
633 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
220 |
208 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
68 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
37 |
$514.50 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$131.46 |
| D0602 |
|
13 |
13 |
$0.00 |
| D0603 |
|
2,732 |
2,388 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |