| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,370 |
198 |
$43K |
| D1110 |
Prophylaxis - adult |
524 |
517 |
$26K |
| D1206 |
Topical application of fluoride varnish |
980 |
943 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
84 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,407 |
747 |
$17K |
| D0274 |
Bitewings - four radiographic images |
452 |
443 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
812 |
797 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
425 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
38 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$5K |
| D0603 |
|
212 |
207 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |