| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,062 |
263 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
1,302 |
1,285 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,582 |
1,568 |
$40K |
| D1110 |
Prophylaxis - adult |
665 |
655 |
$38K |
| D1120 |
Prophylaxis - child |
691 |
683 |
$28K |
| D0274 |
Bitewings - four radiographic images |
460 |
458 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,243 |
624 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
832 |
816 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
51 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
239 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
32 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$1K |