| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,524 |
1,348 |
$77K |
| D1120 |
Prophylaxis - child |
2,836 |
2,746 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,173 |
2,104 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,157 |
1,118 |
$40K |
| D1206 |
Topical application of fluoride varnish |
3,220 |
3,113 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,660 |
1,612 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
293 |
$21K |
| D0274 |
Bitewings - four radiographic images |
982 |
939 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,673 |
1,191 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
250 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,371 |
1,313 |
$12K |
| D1110 |
Prophylaxis - adult |
352 |
337 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
143 |
120 |
$2K |