| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,344 |
613 |
$75K |
| D1110 |
Prophylaxis - adult |
1,113 |
1,108 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,626 |
1,621 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,124 |
1,119 |
$30K |
| D1120 |
Prophylaxis - child |
945 |
944 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,352 |
1,347 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
618 |
617 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,170 |
1,162 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,095 |
917 |
$8K |
| D0272 |
Bitewings - two radiographic images |
509 |
505 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
38 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
109 |
$2K |