| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,753 |
1,092 |
$156K |
| D1120 |
Prophylaxis - child |
2,589 |
2,589 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
2,979 |
2,979 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,567 |
2,567 |
$68K |
| D4341 |
|
248 |
121 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,590 |
1,590 |
$31K |
| D1110 |
Prophylaxis - adult |
538 |
538 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
271 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
822 |
821 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,691 |
2,679 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,433 |
2,420 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
145 |
$10K |
| D0272 |
Bitewings - two radiographic images |
659 |
659 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
365 |
359 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$873.05 |
| D1999 |
|
403 |
380 |
$0.00 |