| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,826 |
368 |
$71K |
| D1110 |
Prophylaxis - adult |
972 |
944 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
431 |
125 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,117 |
1,087 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
756 |
728 |
$16K |
| D1206 |
Topical application of fluoride varnish |
830 |
804 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
626 |
599 |
$10K |
| D0330 |
Panoramic radiographic image |
123 |
119 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
134 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
28 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
13 |
$3K |
| D2394 |
|
27 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
29 |
$384.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$137.40 |