| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
1,751 |
243 |
$42K |
| D1351 |
Sealant - per tooth |
759 |
92 |
$18K |
| D1110 |
Prophylaxis - adult |
358 |
350 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
308 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
41 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
26 |
$4K |
| D0330 |
Panoramic radiographic image |
122 |
121 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
168 |
166 |
$3K |
| D1206 |
Topical application of fluoride varnish |
149 |
147 |
$3K |
| D1310 |
|
188 |
186 |
$2K |
| D1330 |
|
184 |
182 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
57 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
76 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$728.38 |